Peter Stewart

Solving Acid-base problems

Stewart Approach
Roop Kishen

Interactive Cases
Joint tutorial with Dr Patrick Honor
8th Critical Care Symposium, Manchester

roopkishen@gmail.com

Reminders!
Decrease in HCO3 is not the cause of acidosis! 3 independent variables determine pH
HCO3 & H+ are NOT independent variable! Best treatment treat the basic problem Never forget to look at the patient
pCO2 SID Total weak acid (ATOT)

Solving metabolic acidosis problems by the bedside Base excess (SBE) from blood gases Calculate SID effect (ignore K+, Mg, +Ca+) {[Na] [Cl]} 38 = SBENaCl Calculate weak acid effect 0.25 x [42 measured albumin] = SBEAlb SBECalc = SBENaCl + SBEAlb Calculate unmeasured anion effect or BEG True SBE (or SBEG) = SBE - SBECalc

Case 1: increasing acidosis!

, 59, post-operative patient Emergency laparotomy for acute abdomen Perforated colonic diverticulum; contained

abscess, no peritoneal soiling Haemodynamically stable Uneventful anaesthesia and surgery Increasing acidosis!!! Admitted to ICU

Case 1
Time pH pCO2 pO2 Bicarb BE Lactate Pre-operative 7.23 4.2 kPa 14.6 kPa (on O2) 20 mmol/l -6.3 mmol/l 1.5 mmol/l Intra-operative 7.11 5.1 kPa 22.6 (ventilated, FiO2 - .5) 15 mmol/l -12.6 mmol/l 1.2 mmol/l

Case 1
Anaesthetist (and surgeon) worried Something is not right! There is increasing acidosis Patient, warm, stable, good UO What is going on???? Intra-operatively given 5000 ml fluid 1000 Hartmanns, rest 0.9% saline and
gelofusin

Case 1
Time pH pCO2 pO2 Bicarb BE Lactate Na Cl Albumin Pre-operative 7.23 4.2 kPa 14.6 kPa (on O2) 20 mmol/l -6.3 mmol/l 1.5 mmol/l 134 mmol/l 101 mmol/l 36 g/l
Intra-operative

Case 1 pre-op status

SID effect: [134-101] 38 = 33-38 = -5
ATOT effect: 0.25 x [42-36] = 0.25 x 6 = +1.5 Total effect on BE = -5 + 1.5 = -3.5

True BE = -6.3 [-3.5] = -6.3 + 3.5 = -2.8

Case 1
Time Pre-operative pH pCO2 pO2 Bicarb BE Lactate Na Cl Albumin Intra-operative 7.11 5.1 kPa 22.6 (ventilated, FiO2 - .5) 15 mmol/l -12.6 mmol/l 1.2 mmol/l 138 mmol/l 115 mmol/l 22 g/l

Case 1 intra-operative
SID effect: [138-115] 38 = 23 -38 = -15
ATOT effect: 0.25 x [42-22] = 0.25 x 20 = +5.0 Total effect on BE = -15 + 5.0 = -10.0

True BE = -12.6 [-10] = -12.6 + 10.0 = -2.6

Case 1 intra-operative

Metabolic acidosis entirely

HCMA due to infusion of large quantities of Cl containing fluid!

Case 2: Shouldnt she be acidotic!

, mid sixties, known COPD Infective exacerbation of COPD; ?LVF Antibiotics, bronchodilators, steroids and

diuretics Acute abdomen on the ward ?Sepsis, ?septic shock Hypotensive, tachycardia, hypoxia, Low UO Blood gases Type 2 Respiratory Failure

Case 2: Ward blood gases

Patient on 24% O2

pH 7.48 pCO2 8.2 kPa pO2 8.9 kPa Bicarb 33.5 mmol/l SBE +7.6

Case 2:
Type 2 respiratory failure???? Septic shock but not acidotic Why????
There is no lactate measurement Electrolytes? ICU admission and resuscitation begun

Case 2:
Original Results (ward)
pH pCO2 pO2 Bicarb SBE Lactate Na Cl PO4 7.48 8.2 kPa 8.9 kPa 33.5 mmol/l +7.6 ? ? ? ?

New results
7.45 8.6kPa 19..7 kPa (on high flow O2) 32.1 mmol/l +7.2 1.6 mmol/l 132 mmol/l 78 mmol/l 18 g/l 0.89 mmol/l

Albumin ?

Case 1 doing the sums!

SID effect: [132-78] 38 = 54 - 38 = +16
ATOT effect: 0.25 x [42- 18] = 0.25 x 24 = +6.0 Total effect on BE = 16 + 6.0 = 22.0

True BE (SBEG) = 7.2 22 = -14.4!!!

Case 2: So?

Large quantity of unmeasured anion

present despite a near normal pH! Acidosis missed by traditional approach Labelled as Type 2 respiratory failure

Acidosis masked due to widened SID

(diuretics) and reduced ATOT

Case 3: Oh my God, whats happening?

35, , known case of intestinal failure High enteric fistula (just below duodenum) Presented after a short & minor illness Stopped her codeine, loperamide (usual

fistula losses <1000 ml/day) Breathless, tachycardic, looked ill on presentation Admitted surgical HDU, ABGs

Case 3: Arterial blood gases!

Blood gases on SHDU pH pCO2 pO2 Bicarb 7.1 1.8 kPa 21.6 (on face mask high flow O2) 4.8 mmol/l

BE
Lactate

-21.6
0.75 mmol/l

All astounded! What is going on?

Case 3: Next steps

??Sepsis, ???PE Various other unknown conditions suspected She had:

Abdominal CT with contrast (Normal) Pulmonary angiogram (Normal) Various other investigations all within normal limits

ICU resident called prescribed infusion of 1.4% NaHCO3! Next morning, still acidotic, breathless, now oliguric Asked to see

Case 3: My doings!
Go and see the patient Take a detailed history She had been feeling a bit rough (had flu!) Although RR did not look much in distress! Afebrile (WWC, Hb etc normal) Stopped loperamide; fistula out put 6l/day! Was dehydrated and tachycardic Now oliguric

Case 3: My doings
Asked for fistula loss Na (106 mmol/l) Losing Na >600 mmol/day Na - 121, Cl 107 (had 0.9% saline as part of

initial resuscitation); Albumin 31 Routine fluids prescribed Stopped bicarbonate infusion Prescribed Hartmanns to replace fistula losses

Case 3 Mystery resolved!

SID effect: [121 - 107] 38 = 14 - 38 = -24
ATOT effect: 0.25 x [42- 31] = 0.25 x 11 = +2.75 Total effect on BE = -24 + 2.75 = -21.25

True BE (SBEG) = -21.6 [-21.25] = -0.35!!!

Case 3: Conclusion
The patient settled. Her subsequent BE settled around -4.5 (as she
was constantly hyponatraemic) This patient demonstrates that you should never interpret blood gases without looking at the patients and trying to relate investigation to the patients conditions

NEVER TREAT THE NUMBER

Case 4: She needs ventilating!

ABG results! pH = 7.52 PCO2 = 13.6 (102) PO2 = 7.6 (57) Bic = 38.4 BE = +14.7

Case 4:
Another lady, Grade I SAH 24 hours wait before admitted to our NHDU Arterial line put in A blood gas
Came to ICU and told me she needs
ventilating!

Case 4
Why does she need ventilating?
Patient conscious Just finished her breakfast! Complaining of head ache A bit confused but otherwise OK Received a lot of f drug in referring
hospital!

Case 4: She needs ventilating!

ABG results! pH = 7.52 PCO2 = 13.6 (102) PO2 = 7.6 (57) Bic = 38.4 BE = +14.7
Na = 132 Cl = 63

Case 4: She needs ventilating!

ABG results! pH = 7.52 PCO2 = 13.6 (102) PO2 = 7.6 (57) Bic = 38.4 BE = +14.7
Na = 132 Cl = 63

ABG later that day pH = 7.48 PCO2 = 8.3 (62.2) PO2 = 15.8 (118.5) Bic = 27.9 BE = +4.3
Na = Cl = 137 91

What have we learned?

Acid-base disorders can be complex Traditional approaches may not explain all
things!! Stewart approach can explain a lot Stewart approach can also point to aetiology

Never interpret blood-gases without reference

to history, examination and the patient!