596

Chapter 92

Strong Ion Difference (SID)

Overview

• The Na+ minus the Cl– concentration of plasma is commonly referred to as the strong
ion difference (SID).
• An increase in the SID is alkalinizing, while a decrease is acidifying.
• Hyperproteinemia and hyperphosphatemia are acidifying, while hypoproteinemia
is alkalinizing.
• Abnormal plasma Na+ concentrations may indicate the presence of excess free water
(i.e., hyponatremia; dilutional acidosis), or a free water deficit (i.e., hypernatremia;
concentration alkalosis).
• Base excess (BE) and base deficit (-BE) are indicators of the overall nonrespiratory
acid-base state, and are determined from a Siggaard-Andersen nomogram using the
plasma pH and Pco2.
• Changes in the BE can be due to free water abnormalities (i.e., Na+ abnormalties),
Cl– abnormalities, plasma protein abnormalities, or to the presence of
unidentified anions.
• Changes in the BE due to any or all of the abnormalities above can be quantitated.

Evaluation of acid-base disturbances acid-base balance. A brief summary of his

based upon consideration of the "Strong Ion
Difference" is a method that has gained accept-
ance because it:
• Quantitates the effects of concentration
alkalosis or dilutional acidosis.
• Reveals [Cl–] abnormalities that otherwise
would be obscured by free water
abnormalities.
• Quantitates the effects of protein
abnormalities.
• Quantitates the total concentration of
unidentified anions.
This method was originally developed by
Peter A. Stewart, and is therefore sometimes
referred to as the Peter Stewart approach to
Copyright © 2015 Elsevier Inc. All rights reserved.
approach follows.
Biological fluids contain water, weak and
strong electrolytes. While strong electrolytes
are, for the most part, fully dissociated in
biological fluids, weak electrolytes are only
partially dissociated (according to their equi-
librium constants; see Chapter 83). Examples of
weak electrolytes are H2CO3, H2O, and protein
(HProt), while strong electrolytes include NaCl,
NaOH, and H3PO4. Water is a very weak elec-
trolyte (Kw' = 4.4 x 10-14, 37°C in plasma), and
for all practical purposes dissociates little into
H+ and OH–.
When equal amounts of two strong elec-
trolytes (e.g., NaOH + HCl) are added to pure
water, they dissociate completely as follows:

NaOH + HCl ——> Na+ + Cl– + H+ + OH–
Note that electroneutrality is maintained.
In this system, H+ and OH– are the dependent
variables, whose concentrations cannot
change unless the difference between the Na+
and Cl– concentrations (i.e., the independent
variables) changes. This difference, known as
the strong ion difference (SID), is fundamental
to understanding Peter Stewart's approach to
acid/base balance:
SID = [Na+] - [Cl–]
The SID is related to the H+ and OH– concen-
trations in the following way:
SID + [H+] - [OH–] = 0
Note from this relationship, that:
A. When the SID increases, the H+ concen-
tration must decrease in order to maintain
electroneutrality:
h [Na+] and/or i [Cl–] = h SID
Since the Na+ concentration is normally
greater than the Cl– concentration, this rela-
tionship holds true:
h SID + i [H+] - [OH–] = 0
Therefore, an increase in the SID is alkalin-
izing.
B. When the SID decreases, the H+ concen-
tration must increase in order to maintain
electroneutrality:
i [Na+] and/or h [Cl–] = i SID
i SID + h [H+] - [OH–] = 0
Therefore, a decrease in the SID is acidifying.
Plasma Proteins and Phosphates
Plasma proteins act like weak acids, with
the total protein concentration ([Prottot]) being
the sum of the ionized ([Prot–]) and buffered
74 Chapter 92 597
([HProt]) forms ([Prottot] = [HProt] + [Prot–]; see
Chapter 84). Thus:
Hyperproteinemia
h [Prottot] = h [HProt] + h [Prot–]
h [HProt] <——> h [H+] + h [Prot–]
Hypoproteinemia
i [Prottot] = i [HProt] + i [Prot–]
i [HProt] <——> i [H+] + i [Prot–]
Note from the above relationships that an
increase in [Prottot] will increase both [HProt]
and [Prot–], thus also increasing the H+ concen-
tration. Therefore, hyperproteinemia is acid-
ifying, while hypoproteinemia is alkalinizing
(assuming nothing else changes; see McAuliffe
JJ, et al, 1986, and Chapter 89). The basic SID
equation can now be expanded to include the
ionized protein concentration [Prot–] as follows:
SID + [H+] - [OH–] - [Prot–] = 0
Organic and inorganic phosphates (H2PO4–/
HPO4=) normally constitute about 5% of all
weak acids in plasma, while protein (Prot–) is
the major weak acid present (see Fig. 85-3).
Although hypophosphatemia usually does not
cause a large enough reduction in total weak
acid to cause perceptible alkalemia, hyper-
phosphatemia (like hyperproteinemia) is acid-
ifying. Therefore the basic SID equation can
be expanded again to include the inorganic
phosphate concentration ([H2PO4–/HPO4=], or,
for convenience, [PO4=_]) as follows:
SID + [H+] - [OH–] - [Prot–] - [PO4=_] = 0
Free Water Abnormalities
Free water abnormalities (i.e., over- or
under-hydration of the extracellular fluid (ECF)
compartment), can also be assessed in terms
of SID and the acid-base state. Consider what
happens to SID during a 10% free water deficit:
598 The Strong Ion Difference (SID)
Normal i/h in Plasma (or blood) pH = Acidemia /
SID = [Na ] – [Cl ]
+ –
140 mM – 102 mM = 38 mM
10% Free Water Deficit
SID = [Na+] – [Cl–]
154 mM – 112 mM = 42 mM
As SID increases during a free water deficit
(e.g., hypertonic dehydration, all else remaining
unchanged), the [H+] must decrease in order to
maintain electroneutrality:
h SID + i [H+] - [OH–] = 0
The same reasoning can be applied to free
water dissociation:
i H2O <——> i H+ + i OH–
The result is a concentration alkalosis. Free
water excess decreases SID, and causes a
dilutional acidosis. The magnitude of a free
water abnormality can be indirectly assessed
through the Na+ concentration (i.e., an increase
denotes a concentration alkalosis, while a
decrease denotes a dilutional acidosis).
Base Excess (BE) and
Base Deficit (-BE)
Base excess and base deficit are indicators
of the overall non-respiratory acid-base state.
These values, which are usually (+) in alkalosis
and (–) in acidosis, are typically defined as
the amount of acid or base that would restore
one liter of blood to normal acid-base compo-
sition at a Pco2 of 40 mmHg. Although this
value cannot be measured directly, it can
be determined from Pco2 and pH using a
standard Siggaard-Andersen Nomogram (Fig.
92-1). Base excess (or base deficit) is usually
reported with other acid-base data by the
clinical laboratory.
In summary to this point, the following defi-
nitions apply in the Peter Stewart approach to
acid-base balance:
Alkalemia. (A change in pH alone will not
define the acid-base subtype.)
h/i in Pco2 = Respiratory Acidosis / Alkalosis.
(A change in the Pco2 may be a reflection
of respiratory compensation to a metabolic
disturbance, or it may result from a primary
respiratory disturbance. As it increases it
is acidifying, and as it decreases it is alka-
linizing.)
i /h in BE = Non-Respiratory (Metabolic)
Acidosis / Alkalosis. (This value can be
obtained from Pco2 and pH using a standard
Siggaard-Andersen nomogram.)
i /h in [Na+] = Indicator of Free Water Excess
/ Deficit. (A free water excess represents a
dilutional acidosis, while a free water deficit
represents a concentration alkalosis.)
h /i in [Cl–] = Hyperchloremic Acidosis /
Hypochloremic Alkalosis. (When a [Na+]
abnormality exists, the [Cl–] concentra-
tion must be corrected before determining
whether a Cl– abnormality exists (see below).
h /i in [Prottot] or Albumin [Alb] = Hyper-
proteinemic Acidosis / Hypoproteinemic
Alkalosis. (Since albumin normally repre-
sents about 60% of plasma protein, it is
sometimes used in place of total protein
to determine whether a hyper- or hypopro-
teinemic state exists.)
h in Unidentified Anions (UA–) = Lactic
Acidosis, Ketoacidosis, etc. (The presence
of unidentified anions is generally synony-
mous with an acidification process).
Example Problem
Variable Lab Value Normal
pH 7.31 7.4
Pco2 30 mmHg 40 mmHg (torr)
BE -10 mEq/L 0 mEq/L (mM)
+
[Na ] 120 mEq/L 140 mEq/L
–
[Cl ] 91 mEq/L 102 mEq/L
[Alb] 4.5 gm% 4.5 gm% (%)
74 Chapter 92 599

Figure 92-1
600 The Strong Ion Difference (SID)
Note the following from this problem:
A. There is an acidemia present: the plasma
pH is 7.31, which is less than the normal
7.4.
B. There is respiratory alkalosis in this patient:
the Pco2 is 30 mmHg, which is 10 mmHg less
than the normal value of 40.
C. There is a non-respiratory acidosis in this
patient: the BE is -10 mEq/L, which is 10
mEq/L less than the normal value of zero.
D. This may be a mixed disturbance; since there
is acidemia present, the non-respiratory
(metabolic) acidosis is most likely the primary
process, with the respiratory alkalosis being
the compensatory response. The non-respi-
ratory contributions to this acid-base distur-
bance deserve further evaluation.
There is hyponatremia in this patient, which
should be treated as an indicator of a free
water excess; therefore a "dilutional acidosis"
is present. The Cl– concentration must be
corrected for the free water abnormality before
deciding if there is also a Cl– abnormality
present. The plasma albumin concentration
is normal, and thus it is assumed that the total
plasma protein concentration is also normal.
Even though there is a free water abnormality
present, unlike the Cl– concentration, there
is no need to correct the observed plasma
protein concentration. Without performing a
quantitative analysis, it cannot be accurately
determined if an acidifying process due to
unidentified strong anions is present.
Quantitative Analysis of This Problem
1) Enter the observed (reported) base excess
(BE) in Table 92-1 below:
BE (Obs) = -10
2) Enter the observed [Na+] (120 mEq/L) in the
table, then calculate and enter the expected
change in BE due to the free water abnor-
mality:
BE (H2O) = -6
3) Enter the observed [Cl–] and the observed
[Na+] in the table, then calculate and enter
the change in BE due to the chloride abnor-
mality:
BE (Cl–) = -4
Note that the following value (part of the
equation) denotes the [Cl–] corrected for the
free water abnormality:
[Cl–]corr = 140 [Cl–] / [Na+] = 140 x 91/120 = 106
4) Enter the observed [Alb] in the table, then
calculate and enter the expected change in
BE due to the albumin abnormality:
BE (Alb) = 0
5) Sum the expected contributions of 2, 3 and 4
above, and subtract them from the observed
BE; be careful of sign. Enter the result as the
predicted contribution to the change in BE
due to the presence of unidentified anions:
BE (UA–) = 0
Note that the above approach uses neither
the HCO3– nor the K+ concentrations (two ingre-
dients of the plasma "anion gap" calculation,
Chapter 86). Since changes in the base excess
due to protein abnormalities can be quantitated
using this method, the total concentration of
unidentified anions (if present) can be more
closely approximated. As stated previously,
the "anion gap" is a weak tool in the presence
of hypoproteinemia.
The constants used in the above equations
were derived using 140 mEq/L as the normal
[Na+], 102 mEq/L as the normal [Cl–], 6.5 gm/
dl as the normal total plasma protein concen-
tration, and 4.5 gm/dl as the normal albumin
concentration. Ideally, normal values from the
laboratory analyzing the sample should be
used. The constants 3.0 for total plasma protein,
 74 Chapter 92 601

Table 92-1
Change in the Observed Base Excess (BE) Due To:
Free Water BE (H2O) = 0.3 ([Na+] - 140) = 0.3 (120 - 140) = -6
Abnormalities
Chloride BE (Cl–) = 102 - (140 [Cl–] / [Na+]) = 102 - 106 = -4
Abnormalities
Albumin BE (Alb) = 3.7 (4.5 - [Alb]) = 3.7 x 0 = 0
Abnormalities
Unidentified Anions BE (UA–) = (-10) - ((-6) + (-4) + 0) = 0
Make up the balance ____
Total is the observed (reported) BE BE (Obs) = -10

and 3.7 for albumin are based on primate in
vivo studies, which indicate that a decrease
in plasma protein of 1 gm/dl produces an
increase in BE of approximately 3.0 mEq/L, and
a 1 gm/dL decrease in the albumin concen-
tration produces an increase in BE of about
3.7 mEq/L. The constant (0.3) used in the free
water equation, which is equal to the SID/
normal [Na+], was also derived from studies
in primates. This constant is 0.25 and 0.22 for
dogs and cats, respectively, while the value of
0.3 is used for other animal species.
As a matter of interpretation for this
example problem, it can be seen that there are
combined dilutional (negative BE (H2O)) and
hyperchloremic acidoses (negative BE (Cl–)),
that account for the observed base deficit.
There is no abnormality in the protein concen-
tration, and there is no need to postulate
the presence of unidentified anions since the
entire observed base deficit is accounted for
by the free water and chloride abnormalities
((-6) + (-4) = -10). It can also be seen from this
example that the reduction in Pco2 (10 mmHg)
has the expected relation to the observed BE
(-10) for this mixed acid/base disturbance (i.e.,
a primary non-respiratory acidosis with a
compensatory respiratory alkalosis).
In summary, primary disturbances in
acid-base balance may be classified as being
either respiratory or nonrespiratory in origin.
Primary respiratory disturbances are fairly
straight-forward since they affect mainly the
plasma Pco2 and [HCO3–] (see Chapters 90 and
91). Nonrespiratory disturbances, also called
"metabolic" disturbances, are usually far more
complex, and therefore their full categorization
requires more than merely assessing changes
in the plasma Pco2 and [HCO3–]. Plasma is
a complex solution with many interacting
constituents, and Peter Stewart successfully
employed basic physicochemical principles of
aqueous solutions to write equations describing
interactions among those constituents. The
primary independent variables controlling the
[H+] of body fluids, and hence the plasma
pH, were found to be the Pco2, SID ([Na+] -
[Cl–]), and the plasma protein concentration
([Prot–]). When the SID increases (i.e., the [Na+]
increases or the corrected [Cl–] decreases),
the [H+] will decrease; and when the [Prot–]
concentration increases, the [H+] will increase
in order to retain electroneutrality:
SID + [H+] - [OH–] - [Prot–] = 0
Note that neither the HCO3– nor the K+ concen-
trations of plasma (two ingredients of the anion
gap) are used in this approach to acid-base
balance.
Traditional methods of evaluating the
acid-base status of an animal have not previ-
ously considered SID or the plasma [Prot–].
602 The Strong Ion Difference (SID)
Equations developed by Fencl and Leith allow
Stewart's work to be easily applied clinically
for evaluating the metabolic (nonrespira-
tory) contribution to acid-base balance. This
approach separates the net metabolic abnor-
mality into various components, and allows
one to easily detect and evaluate the nature of
mixed metabolic acid-base disturbances which
might otherwise remain as hidden abnormal-
ities. This approach also provides insight into
the severity of those disturbances.
OBJECTIVES
• Explain how the Peter Stewart approach to
acid-base balance differs from the more tradi-
tional Henderson-Hasselbalch approach.
• Discuss what is meant by the SID (also called
the fixed ion difference (FID) or in some cases
the dietary cation-anion difference (DCAD)), and
how it influences pH.
• Recognize the pathophysiologic implications of
the following equation: SID + [H+] - [OH–] - [Prot–
] - [PO4=] = 0
• Explain why a free water deficit is alkalinizing,
and why the plasma [Na+] is used to assess a
free water abnormality.
• Show how the plasma Pco2 and pH can be used
to determine an observed base excess/deficit.
• Understand how the constants used in deter-
mining changes in the observed BE due to free
water and protein abnormalities were deter-
mined.
• Recognize why hyperphosphatemia affects
plasma pH more than hypophosphatemia (see
Chapter 85).
• Understand why the plasma [Cl–] does not need
to be corrected unless there is a free water
abnormality present.
• Know why there is no reason to postulate the
presence of unidentified ions when the sum of the
contributions to the BE due to the free water, Cl–
and protein abnormalities equal the observed BE.
• Explain why the plasma [HCO3–], [K+] and AG are
not formerly considered in the Peter Stewart
approach to acid-base balance.
• Understand how contributions to the acid-base
state due to the presence of unidentified anions
are quantitated.
• Understand how the constants in the free water
equation and in the protein equations were
derived.
• Explain how (and why) hyponatremia becomes
acidifying, while hypochloremia is alkalinizing.
• Understand how and why the Peter Stewart
approach to acid-base balance does not neces-
sarily replace the more traditional approach, but
merely adds to our understanding of acid-base
disorders.
QUESTIONS with Explanations:
1. Given the following information on a
patient:
Variable Lab Value Normal
pH 7.33 7.4
Pco2 49 mmHg 40 mmHg
BE 0 mEq/L 0 mEq/L
[Na+] 140 mEq/L 140 mEq/L
[Cl–] 102 mEq/L 102 mEq/L
[Alb] 4.5 gm% 4.5 gm%
a. Unidentified anions are present.
b. Pure uncompensated metabolic acidosis
accounts for this acid-base disturbance.
c. There is a net non-respiratory abnor-
mality present.
d. Acute respiratory acidosis accounts for
this acid-base disturbance.
e. The observed chloride concentration
needs to be corrected since there is a free
water abnormality present.
BE (H2O) = 0
BE (Cl–) = 0
BE (Alb) = 0
BE (UA–) = 0
———————
BE (Obs) = 0
Both acidemia (pH = 7.33) and respiratory
acidosis (Pco2 = 49) are present, yet there is
no net non-respiratory abnormality (BE = 0).
There is no abnormality of free water, so there
is neither concentration alkalosis nor dilutional
acidosis present. For the same reason, the

observed [Cl–] needs no correction, and is seen
to be normal. The [Alb] is normal, and there is
no need to infer the presence of unidentified
anions. This acid-base disturbance is primarily
respiratory acidosis, which could be an acute
condition such as hypoventilation without time
for renal compensation, where hyperbicarbo-
natemia and hypochloremia would be expected
(see Chapter 90).
2. Given the following information on a
patient:
Variable Lab Value Normal
pH 7.31 7.4
Pco2 30 mmHg 40 mmHg
BE -10 mEq/L 0 mEq/L
[Na+] 140 mEq/L 140 mEq/L
[Cl–] 102 mEq/L 102 mEq/L
[Alb] 4.5 gm% 4.5 gm%
a. There is no need to postulate the presence
of unidentified anions in this patient.
b. There is a dilutional acidosis present.
c. This patient has a primary respiratory
acidosis.
d. The Cl– concentration needs to be
corrected due to the presence of a free
water abnormality.
e. There is a primary non-respiratory
acidosis in this patient with unidentified
anions present.
BE (H2O) = 0
BE (Cl–) = 0
BE (Alb) = 0
BE (UA–) = -10
————————
BE (Obs) = -10
There is acidemia, respiratory alkalosis and
a net non-respiratory acidosis present. There
is no abnormality of free water, so there is
neither a concentration alkalosis nor a dilu-
tional acidosis present. For the same reason,
the observed [Cl–] needs no correction, and
is observed to be normal. The [Alb] is also
normal, so these three cannot totally account
for the observed base excess (-10). We must
therefore postulate the presence of unidenti-
fied anions totaling 10 mEq/L.
74 Chapter 92 603
This acid/base disturbance would be clas-
sified as a primary non-respiratory acidosis
due to the presence of unidentified anions. It
has apparently been present long enough (6-24
hrs) for a compensatory respiratory alkalosis to
become established (Fig. 87-2 and Table 87-2).
What might these unidentified anions be?
If there is reason to suspect that the cardiac
output is low, lactic acidosis (from anaerobic
metabolism) would be likely. However, there
are other possible unidentified anions as well;
ketone bodies (acetoacetate or b-hydroxybu-
tyrate that accumulate during starvation or in
diabetic ketoacidosis), other organic anions
generated from ingestion of toxic substances
like aspirin, antifreeze or methanol, or sulfates
that accumulate in chronic renal failure (see
Chapters 82, 87, and 88).
3. Given the following information on a
patient:
Variable Lab Value Normal
pH 7.40 7.40
Pco2 40 mmHg 40 mmHg
BE 0 mEq/L 0 mEq/L
[Na+] 160 mEq/L 140 mEq/L
[Cl–] 124 mEq/L 102 mEq/L
[Alb] 4.5 gm% 4.5 gm%
a. There is a free water deficit with concen-
tration acidosis present.
b. There is a hyperchloremic acidosis
present.
c. There are unidentified anions present.
d. The observed pH is normal, so there are
no acid-base abnormalities in this patient.
e. None of the above.
BE (H2O) = +6
BE (Cl–) = -6
BE (Alb) = 0
BE (UA–) = 0
————————
BE (Obs) = 0
The pH and Pco2 are normal, and there is no
net base excess. However, a free water deficit
is present denoting a concentration alkalosis.
The corrected [Cl–] is abnormal (i.e., 108 mEq/L,
604 The Strong Ion Difference (SID)
which has increased 6 mEq/L (hyperchloremic
acidosis)), while the [Alb] is normal. These
three (+6 -6 +0) account for the observed base
excess (0), so there is no need to postulate the
presence of unidentified anions. This appears to
be a case of two offsetting metabolic conditions;
a concentration alkalosis (free water deficit),
offset equally by a hyperchloremic acidosis.
4. Given the following information on a
patient:
Variable Lab Value Normal
pH 7.40 7.40
Pco2 40 mmHg 40 mmHg
BE 0 mEq/L 0 mEq/L
[Na+] 140 mEq/L 140 mEq/L
[Cl–] 102 mEq/L 102 mEq/L
[Alb] 2.3 gm% 4.5 gm%
a. Since the pH, Pco2 and BE are normal,
there is no acid-base disturbance here.
b. This is a case of pure hypoproteinemic
acidosis.
c. There is a significant acidosis from
unidentified anions that is hidden.
d. This is a case of pure hypoproteinemic
alkalosis.
e. None of the above.
BE (H2O) = 0
BE (Cl–) = 0
BE (Alb) = +8
BE (UA–) = -8
———————
BE (Obs) = 0
The pH and Pco2 are normal, and there is no
net base excess present (BE (Obs) = 0). There
is no free water abnormality, so there is neither
concentration alkalosis nor dilutional acidosis
present. For the same reason, the observed
[Cl–] needs no correction, and is observed to
be normal. The [Alb] is down by 2.2 g/dl, so
there is a hypoproteinemic alkalosis present
that would make the base excess = +8 mEq/L.
To account for the observed base excess of
0 mEq/L, one must postulate the presence of
unidentified anions in the amount of -8 mEq/L.
There is a significant acidosis present from
unidentified anions that is hidden (observed BE
= 0) by the presence of an equally offsetting
hypoproteinemic alkalosis. Since these two
metabolic acid-base disturbances are equally
offsetting, there is no need for respiratory
compensation.
5. Given the following information on a
patient:
Variable Lab Value Normal
pH 7.40 7.40
Pco2 40 mmHg 40 mmHg
BE 0 mEq/L 0 mEq/L
[Na+] 140 mEq/L 140 mEq/L
[Cl–] 114 mEq/L 102 mEq/L
[Alb] 1.3 gm% 4.5 gm%
a. Unidentified anions are present as a
hidden abnormality
b. The observed [Cl–] needs to be corrected
c. This is a marked hyperchloremic acidosis
masked by a hypoproteinemic alkalosis
d. This is a marked hyperchloremic alkalosis
masked by a hypoproteinemic acidosis
e. None of the above
BE (H2O) = 0
BE (Cl–) = -12
BE (Alb) = +12
BE (UA–) = 0
———————
BE (Obs) = 0
A normal pH and Pco2 are present, and there
is no net base excess. There is no abnormality
of free water, so there is neither a concentra-
tion alkalosis nor a dilutional acidosis present.
For the same reason, the observed [Cl–] needs
no correction, yet is seen to be 12 mEq/L above
normal (a hyperchloremic acidosis). The [Alb]
is down by 3.2 g/dl, which through quantitative
analysis reveals an equally offsetting hypo-
proteinemic alkalosis. These two marked, yet
offsetting metabolic abnormalities account for
the entire observed base excess (0), so there is

no need to postulate the presence of unidenti-
fied anions.
6. Given the following information on a
patient:
Variable Lab Value Normal
pH 7.40 7.40
Pco2 40 mmHg 40 mmHg
BE 0 mEq/L 0 mEq/L
[Na+] 160 mEq/L 140 mEq/L
[Cl–] 123 mEq/L 102 mEq/L
[Alb] 2.3 gm% 4.5 gm%
a. There is a concentration alkalosis present.
b. Unidentified anions are present in the
amount of -8 mEq/L.
c. There are four hidden non-respiratory
acid-base abnormalities present that
offset one another.
d. All of the above are true.
e. There is no acid-base abnormality here
since the pH and Pco2 are normal, and
there is no net base excess.
BE (H2O) = +6
BE (Cl–) = -6
BE (Alb) = +8
BE (UA–) = -8
————————
BE (Obs) = 0
The plasma pH and Pco2 in this patient are
normal, and there is no net base excess.
However, there is a concentration alkalosis
present, as well as a hyperchloremic acidosis
and a hypoproteinemic alkalosis. These sum
to BE = +8, but the observed base excess is
zero. One must, therefore, infer the presence
of unidentified anions in the amount of -8
mEq/L. Thus, there are four hidden non-res-
piratory acid-base abnormalities in this patient
that tend to offset one another (i.e., the pH and
Pco2 are normal), with the net (observed) base
excess being zero.
74 Chapter 92 605
7. Given the following information on a
patient:
BE (H2O) = +0.3
BE (Cl–) = -2
BE (Alb) = ?
BE (UA–) = -0.1
————————
BE (Obs) = +4.2
pH = 7.37 (Normal 7.40)
Pco2 = 53 mmHg (Normal = 40)
AG = 8.8 mEq/L
a. The observed base excess is due solely to
a free water abnormality.
b. There is a concentration alkalosis, hyper-
chloremic acidosis and hyperproteinemic
acidosis present.
c. There is a hypoproteinemic alkalosis
present which causes the plasma anion
gap (AG) to be subnormal.
d. This patient has respiratory acidosis
(which can account for the entire change
in pH as well as the observed base
excess).
e. None of the above
Although the contribution to the base excess
due to the protein abnormality (BE (Alb)) was
not given in this problem, it can be calculated
from the data given:
BE (Alb) = 4.2 - 0.3 + 2 + 0.1 = +6
Thus, there is a marked hypoproteinemic
alkalosis present (BE (Alb) = +6), which causes
the plasma anion gap to be low (AG = 8.8
mEq/L). This patient also has a hyperchloremic
acidosis (BE (Cl–) = -2), and a mild concen-
tration alkalosis (BE (H2O) = +0.3). There is a
7. c
significant ongoing respiratory acidosis (Pco2 6. d
= 53 mmHg), and unidentified strong anions are 5. c
present which contributes to the overall net
4. c
acidemia (pH = 7.37).
3. b
2. e
1. d
ANSWERS