Acid-base balance controversy. Case for standard-base excess as the measure of nonrespiratory acid-base imbalance

Assessing Acid-Base Status: Physiologic Versus Physicochemical Approach

The physiologic approach has long been used in assessing acid-base status. This approach considers acids as hydrogen ion donors and bases as hydrogen ion acceptors and the acid-base status of the organism as reflecting the interaction of net hydrogen ion balance with body buffers. In the physiologic approach, the carbonic acid/bicarbonate buffer pair is used for assessing acid-base status and blood pH is determined by carbonic acid (ie, Paco₂) and serum bicarbonate levels. More recently, the physicochemical approach was introduced, which has gained popularity, particularly among intensivists and anesthesiologists. This approach posits that the acid-base status of body fluids is determined by changes in the dissociation of water that are driven by the interplay of 3 independent variables: the sum of strong (fully dissociated) cation concentrations minus the sum of strong anion concentrations (strong ion difference); the total concentration of weak acids; and Paco₂. These 3 independent variables mechanistically determine both hydrogen ion concentration and bicarbonate concentration of body fluids, which are considered as dependent variables. Our experience indicates that the average practitioner is familiar with only one of these approaches and knows very little, if any, about the other approach. In the present Acid-Base and Electrolyte Teaching Case, we attempt to bridge this knowledge gap by contrasting the physiologic and physicochemical approaches to assessing acid-base status. We first outline the essential features, advantages, and limitations of each of the 2 approaches and then apply each approach to the same patient presentation. We conclude with our view about the optimal approach.

Point-of-care blood gas and electrolyte analysis in rabbits

This article outlines a practical approach for the use of blood-gas analysis in pet rabbits using the I-STAT analyzer. Sampling techniques and a theoretic approach to diagnosis are described. The following 95% RI were obtained from venous samples of 45 healthy rabbits: pH (7.245-7.533), PCO(2) (28.9-52.9 mm Hg), HCO(3) (17.0-32.5 mmol/L), total CO(2) (18-34 mmol/L), BE(ecf) (-10-8 mmol/L), AnGap (11-26 mmol/L), Na (136-147 mmol/L), K (3.4-5.7 mmol/L), Cl (93-113 mmol/L), Glu (93-245 mg/dL), BUN (9-33 mg/dL). Results from 20 arterial samples were pH (7.358-7.502), PCO(2) (29.1-36.8 mm Hg), HCO(3) (17.5-27.6 mmol/L), BE(ecf) (-7-5 mmol/L), PO(2) (75-101 mm Hg), iCa (1.67-1.85). The article also includes some conclusions obtained comparing results from healthy and ill rabbits over an 18-month period.

Making sense of blood gas results

Recent technologic advances have allowed the production and marketing of cage-side blood gas analyzers to private practitioners. The widespread use of cage-side portable blood gas analyzers in veterinary practices has increased the need to develop the basic skills of blood gas analysis as part of a tool kit for practicing veterinarians. Rapid expansion of emergency and critical care medicine as a specialty and increased numbers of veterinary emergency and veterinary specialty practices have occurred concurrently with the availability of blood gas analyzers that are affordable for private practitioners. As a result, evaluation of blood gas results is no longer an activity confined to academic institutions and has become a daily part of many practicing veterinarians' activities.

Acid-base analysis: a critique of the Stewart and bicarbonate-centered approaches

When approaching the analysis of disorders of acid-base balance, physical chemists, physiologists, and clinicians, tend to focus on different aspects of the relevant phenomenology. The physical chemist focuses on a quantitative understanding of proton hydration and aqueous proton transfer reactions that alter the acidity of a given solution. The physiologist focuses on molecular, cellular, and whole organ transport processes that modulate the acidity of a given body fluid compartment. The clinician emphasizes the diagnosis, clinical causes, and most appropriate treatment of acid-base disturbances. Historically, two different conceptual frameworks have evolved among clinicians and physiologists for interpreting acid-base phenomena. The traditional or bicarbonate-centered framework relies quantitatively on the Henderson-Hasselbalch equation, whereas the Stewart or strong ion approach utilizes either the original Stewart equation or its simplified version derived by Constable. In this review, the concepts underlying the bicarbonate-centered and Stewart formulations are analyzed in detail, emphasizing the differences in how each approach characterizes acid-base phenomenology at the molecular level, tissue level, and in the clinical realm. A quantitative comparison of the equations that are currently used in the literature to calculate H+concentration ([H+]) is included to clear up some of the misconceptions that currently exist in this area. Our analysis demonstrates that while the principle of electroneutrality plays a central role in the strong ion formulation, electroneutrality mechanistically does not dictate a specific [H+], and the strong ion and bicarbonate-centered approaches are quantitatively identical even in the presence of nonbicarbonate buffers. Finally, our analysis indicates that the bicarbonate-centered approach utilizing the Henderson-Hasselbalch equation is a mechanistic formulation that reflects the underlying acid-base phenomenology.

Carboxyhemoglobin half-life in carbon monoxide-poisoned patients treated with 100% oxygen at atmospheric pressure

STUDY OBJECTIVES

There are large reported differences for the carboxyhemoglobin (COHb) half-life (COHb t(1/2)) in humans breathing 100% atmospheric O(2) following CO inhalation in tightly controlled experiments compared to the COHb t(1/2) observed in clinical CO poisoning (range, 36 to 131 min, respectively). Other reports have suggested that the COHb t(1/2) may be affected by gender differences, age, and lung function. We wished to test the hypothesis that the COHb t(1/2) might also be influenced by CO poisoning vs experimental CO exposure, by a history of loss of consciousness (LOC), concurrent tobacco smoking, and by PaO(2). The purpose of the present study was to measure the COHb t(1/2) in a cohort of CO-poisoned patients and to determine if those listed factors influenced the COHb t(1/2).

DESIGN

Retrospective chart review from 1985 to 1995. We calculated the COHb t(1/2) of CO-poisoned patients who were treated with high-flow supplemental atmospheric pressure O(2) delivered by nonrebreather face mask or endotracheal tube.

SETTING

Hyperbaric medicine department of a tertiary-care teaching hospital.

PATIENTS

Of 240 CO-poisoned patients, 93 had at least two COHb measurements > 2% (upper limit of normal) with recorded times of the measurements, permitting calculation of the COHb t(1/2).

RESULTS

The COHb t(1/2) was 74 +/- 25 min (mean +/- 1 SD) with a range from 26 to 148 min. By stepwise multiple linear regression analysis, the PaO(2) influenced the COHb t(1/2) (R(2) = 0.19; p < 0.001), whereas the COHb t(1/2) was not influenced by gender, age, smoke inhalation, history of LOC, concurrent tobacco smoking, degree of initial metabolic acidosis (base excess), or initial COHb level.

CONCLUSIONS

The COHb t(1/2) of 93 CO-poisoned patients treated with 100% O(2) at atmospheric pressure was 74 +/- 25 min, considerably shorter than the COHb t(1/2) reported in prior clinical reports (approximately 130 +/- 130 min) and was influenced only by the patient's PaO(2).

PCO2 electrodes at the surface of the kidney detect ischaemia

BACKGROUND

Under ischaemic (anaerobic) conditions there will be an accumulation of CO2 in the tissue secondary to a build up of protons that is buffered by HCO3. We reasoned that CO2 could be measured at the surface of the kidney by PCO2 electrodes to detect ischaemic conditions.

METHODS

Anaesthetized, mechanically ventilated pigs (25-30 kg) were investigated. Two acute porcine models, one of haemorrhagic shock and one of renal artery stenosis were used. Renal blood flow was gradually decreased, either by successive episodes of bleeding through the arterial cannula or by successive snaring of the renal artery.

RESULTS

In both models we found that with decreased blood flow but maintained aerobic metabolism (supply independence) PCO2 both at the surface of the kidney and in the renal vein increased by 2-3 kPa. Thus, the tissue-venous PCO2 difference did not change much. At DO2crit, i.e., at the transition to supply-dependent O2 consumption, the tissue PCO2 started to increase rapidly, as did the tissue-venous PCO2 difference. This is compatible with the notion that a hallmark of ischaemia is decreased ability of the blood to transport away waste products because the contact between large parts of tissue and blood is virtually non-existent. In the renal artery stenosis model kidney surface PCO2 values rose from a baseline of 6.6 +/- 0.6 kPa (mean +/- SEM) to a value near DO2crit of 10.6 +/- 0.8 kPa, reaching a final value of 29.9 +/- 3.5 kPa at no flow. PCO2 in the renal vein, however, reached a maximum of only 8.2 +/- 0.6 kPa. Numbers very similar to these were also found in the haemorrhagic model. The urine production decreased before the onset of ischaemia. When surface PCO2 values increased sharply indicating ischaemia, the urine production was zero. Lactate production by the kidney correlated very well with increasing tissue PCO2 values further corroborating that anaerobic metabolism was detected with the electrodes.

CONCLUSION

We conclude that PCO2 electrodes placed at the surface of the kidney detect renal cortical ischaemia.