CHAPTER 4

Historical Background of the Acid-Base

Physiology Debate
Fundamental Principles of Hydrogen Ion
Regulation
Biochmistry of Aqueous Solutions
Strong Ion Defference, Pco2, and Total Weak Acid
Concentration
Clinical Applications
Quantification of Acid-Base Disorders
Chloride: the *forgotten Electrolyte*
Other Anions
Treatment of Acidosis and/or Acidemia
Other Mechanisms of Lactic Acidosis
The Artificial Kidney and Lactate
Effects of Plasma Proteins

Conclusion

Significant advances in medicine, like other fields of science, are the products of multiple individual
discoveries, usually by many different people, often over many years. Furthermore, pivotal advances,
those that after the very way we look at a particular issue, occur only very rarely given the thousands of
individual investigators who contribute to the collective literature of science and medicine. These
paradigm shifts are often met with great resistance in part because they require us to unlearn the old way
as much as they require us to learn something new. When it was first reported that peptic ulcer disease
was due to H. pylori infection, the scientific community reacted slowly and then with skepticism.

Little more than 20 years ago Peter Stewart published his revolutionary physical chemical analysis of
acid-base physiology. Stewart’s approach to acid-base was praised by some and criticized by others, but
mostly it was ignored. Indeed, there has been very little interest in this approach untill quite recently. It
wouldseem that the disinterest was due mainly to the fact that the approach, while conceptually simple
and elegant, is operationally complicated and unwieldy. Most clinicians feel quite comfortable with the
traditional approach to acid-base physiology and few can be easily conviced that “re-learning” this area is
worthwhile. However, for patients in the intensive care unit (ICU), extreme derangements in physiology
are common and traditional methods are often inadequate to explain in the severe acid-base disorders
present in some of these patients. Although the Stewart approaach is based on the same physical chemical
principles on which more traditional approaach are based, this new approaach is vastly different. The
most important difference is that, in this view of the biological universe, hydrogen ions and bicarbonate
ions are not independent variables but are insted determined by other factors. Change in PH are not the
result of the generation or removal of these ions per se, but rather are the result of change in other
variables. In this universe, it is the earth rather than the sun that moves.
The stewart approaach has now been found very robust in a wide variety of patient types and
experimental conditions. Recenly, it has been shown that quantitatively this approaach is compatiblewith
the more traditional approaaches, the difference lies in the understanding of the mechanism involved. The
observation that metabolic acidosis is associated with a decrease in plasma bicarbonate and base exces
remains valid. However, the implication that these changes cause the acidosis is not. Some might argue
that such a conceptual change makes little difference. If one can measurethe size and origin (respiratory
vs metabolic) of a change in acid-base status. Does the average clinician really need to understand how it
occurs ? of course, this was the same argument facing galileo when he insisted that the earth was not the
center of the universe. Even without

Historical Background of the Acid-Base

Physiology Debate
Fundamental Principles of Hydrogen Ion
Regulation
Biochmistry of Aqueous Solutions
Strong Ion Defference, Pco2, and Total Weak Acid
Concentration
Clinical Applications
Quantification of Acid-Base Disorders
Chloride: the *forgotten Electrolyte*
Other Anions
Treatment of Acidosis and/or Acidemia
Other Mechanisms of Lactic Acidosis
The Artificial Kidney and Lactate
Effects of Plasma Proteins

Kesimpulan

kemajuan signifikan dalam pengobatan, seperti bidang ilmu pengetahuan lainnya, adalah produk
dari beberapa penemuan individual, biasanya dengan banyak orang yang berbeda, sering selama
bertahun-tahun. Selanjutnya, kemajuan penting, orang-orang yang setelah cara yang sangat kita
melihat isu tertentu, hanya terjadi sangat jarang mengingat ribuan peneliti perorangan yang
memberikan kontribusi pada literatur kolektif ilmu pengetahuan dan kedokteran. pergeseran
paradigma ini sering bertemu dengan perlawanan besar sebagian karena mereka membutuhkan
kita untuk melupakan cara lama sebanyak yang mereka mengharuskan kita untuk mempelajari
sesuatu yang baru. Ketika pertama kali dilaporkan bahwa penyakit ulkus peptikum adalah karena
infeksi H. pylori, komunitas ilmiah bereaksi perlahan-lahan dan dengan skeptisisme.

Sedikit lebih dari 20 tahun yang lalu Peter Stewart menerbitkan analisis kimia nya revolusioner
fisik asam-basa fisiologi. Pendekatan Stewart untuk asam-basa dipuji oleh beberapa dan dikritik
oleh orang lain, tapi sebagian besar diabaikan. Memang, ada sangat sedikit minat dalam
pendekatan ini sampai cukup baru-baru ini. Ini wouldseem bahwa ketidaktertarikan itu terutama
karena fakta bahwa pendekatan, sementara konseptual sederhana dan elegan, secara operasional
rumit dan berat. Kebanyakan dokter merasa cukup nyaman dengan pendekatan tradisional untuk
asam-basa fisiologi dan beberapa dapat dengan mudah conviced bahwa "re-learning" daerah ini
berharga. Namun, untuk pasien di unit perawatan intensif (ICU), derangements ekstrim dalam
fisiologi yang umum dan metode tradisional sering tidak memadai untuk menjelaskan dalam
gangguan asam-basa berat hadir dalam beberapa pasien. Meskipun approaach Stewart didasarkan
pada prinsip-prinsip kimia fisik yang sama yang approaach lebih tradisional didasarkan,
approaach baru ini sangat berbeda. Perbedaan yang paling penting adalah bahwa, dalam
pandangan ini alam semesta biologi, ion hidrogen dan ion bikarbonat yang tidak variabel
independen tetapi insted ditentukan oleh faktor lain. Perubahan PH bukanlah hasil dari generasi
atau penghapusan ion ini per se, melainkan merupakan hasil dari perubahan variabel lain. Di
alam semesta ini, itu adalah bumi daripada matahari yang bergerak.

The stewart approaach sekarang telah ditemukan sangat kuat dalam berbagai jenis pasien dan
kondisi eksperimental. Recenly, telah menunjukkan bahwa secara kuantitatif approaach ini
compatiblewith yang approaaches lebih tradisional, perbedaan terletak pada pemahaman tentang
mekanisme yang terlibat. Pengamatan bahwa asidosis metabolik dikaitkan dengan penurunan
plasma bikarbonat dan basis Exces tetap berlaku. Namun, implikasi bahwa perubahan ini
menyebabkan asidosis tidak. Beberapa mungkin berpendapat bahwa seperti perubahan
konseptual membuat sedikit perbedaan. Jika seseorang dapat measurethe ukuran dan asal
(pernapasan vs metabolisme) dari perubahan status asam-basa. Apakah dokter rata-rata benar-
benar perlu memahami bagaimana hal itu terjadi? tentu saja, ini adalah argumen yang sama
menghadapi Galileo ketika ia bersikeras bahwa bumi bukanlah pusat alam semesta. Bahkan
tanpa