Avoiding Iatrogenic Hyperchloremic Acidosis—Call for a New Crystalloid Fluid

“…The debate on balanced, plasma-adapted solutions started in the 1970s, when their features were first described. A new definition was proposed in 2000 in "Avoiding Iatrogenic Hyperchloremic Acidosis: Call for a New Crystalloid Fluid," published in Anesthesiology, which referred to the classic need of "a solution containing sodium bicarbonate" because it was clear that "…the predominate physiologic deficit is metabolic acidosis…" (Dorje et al 2000). Subsequent developments were summarized in 2003 by Reid et al (2003), who highlighted that scientists and clinicians must inevitably reach a compromise in their long-standing attempts to find the ideal physiological solution.…”

Section: Which Kind Of Fluid?mentioning

confidence: 99%

Fluid Management and Electrolyte Balance

Vennari

Benedetto

2013

Postoperative Critical Care for Cardiac Surgical Patients

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“…Hier tritt also gerade der Fall ein, dass sich nominell der pH und der Base excess nicht verändern,die traditionellen Konzepte damit auch keine Säure-BasenStörung aufzeigen, die Anwendung des Stewart-Modells hingegen das Vorhandensein zweier verschiedener, sich über-lagernder,Säure-Basen-Störungen erkennen lässt. Im Anschluss an diese Arbeit entbrannte eine teils enthusiastische aber durchaus auch kontroverse Diskussion [5,6,19,26,41,65,69,71,79,98,105]. So wurde in einem Lehrbuchartikel von einer "völlig verfehlten Beweisführung" geschrieben,da bekanntermaßen das in der Ringer-Laktat-Gruppe zugeführte Laktat zu Bikarbonat verstoffwechselt würde und dementsprechend die Bikarbonatkonzentration nicht (wie in der NaCl-Gruppe) abfallen könne [105].…”

Section: Säure-basen-veränderungen Während Infusionstherapieunclassified

“…Für den Interessierten sind im Appendix 2 Internetseiten aufgelistet,anhand derer der praktische Umgang mit Stewarts Analytik geübt werden kann.Die Industrie wird gleich in zweierlei Hinsicht gefordert sein: Zum einen im Hinblick auf die Entwicklung von Blutgasanalysatoren,die eine exakte Bestimmung der SID (vielleicht auch von [A − ]?) ermöglichen und zum anderen, bezüglich der Entwicklung wirklich "physiologischer" Infusionslösungen [19,27,50,91].Stellt sich heraus,dass Stewarts Analytik den Mikrokosmos des Säure-Basen-Haushalts besser beschreibt als die traditionelle Lehre -und darauf deutet mittlerweile vieles hin -, wird sie unaufhaltsam ihren Weg in die großen Lehrbü-cher finden.Falls nicht,bleibt es ein faszinierendes, alternatives Modell zur Erklä-rung des Säure-Basen-Haushalts.…”

Section: Der Anaesthesist 4 · 2004 352unclassified

Das Stewart-Modell

et al. 2004

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About twenty years ago, Peter Stewart had already published his modern quantitative approach to acid-base chemistry. According to his interpretations, the traditional concepts of the mechanisms behind the changes in acid-base balance are considerably questionable. The main physicochemical principle which must be accomplished in body fluids, is the rule of electroneutrality. There are 3 components in biological fluids which are subject to this principle: a)Water, which is only in minor parts dissociated into H+ and OH-, b)"strong", i.e. completely dissociated, electrolytes, which thus do not interact with other substances, and body substances, such as lactate, and c)"weak", i.e. incompletely dissociated, substances. Peter Stewart strictly distinguished between dependent and independent variables and thus indeed described a new order of acid-base chemistry. The 3 dependent variables (bicarbonate concentration [Bic(-)], pH, and with this also hydrogen ion concentration [H(+)]) can only change if the 3 independent variables allow this change. These 3 independent variables are: 1. Carbon dioxide partial pressure, 2.the total amount of all weak acids ([A-] (Stewart called these ATOT), and 3.strong ion difference (SID). [A(-)] can be calculated from the albumin (Alb) and the phosphate concentration (Pi): [A(-)]=[Alb x (0.123 x pH - 0.631)] + [Pi x (0.309 x pH - 0.469)]. An apparent SID (or "bedside" SID) can be calculated using measurable ion concentrations: SID=[Na(+)] + [K(+)] - [Cl(-)]-lactate. Regarding the metabolic disturbances of acid-base chemistry, according to Stewart's terminology, changes in pH, [H(+)], and [Bic(-)] are only possible if either SID or [A(-)] itself changes. If, for example, SID decreases (e.g. in case of hyperchloremia), this increase in independent negative charges leads to a decrease in dependent negative charges in terms of [Bic(-)] resulting in acidosis (and vice versa). Therefore, according to Stewart, the decrease in SID during hyperchloremic acidosis results from the increase in serum chloride concentration and is the causal mechanism behind this acidosis. Contrary for example, a decrease in [A(-)] (e. g. during hypoalbuminemia) leads to an increase in [Bic(-)] and therefore to an alcalosis (and vice versa). Thus, by Stewart's approach, completely new acid-base disturbances, like "hyperchloremic acidosis" or "hypoalbuminemic alcalosis" (which, of course, can also exist in combination) can be detected, which had been unrecognised by the classic acid-base concepts. Consequently, Stewart's analysis can lead to a better understanding of the mechanisms behind the changes in acid-base balance.

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Avoiding Iatrogenic Hyperchloremic Acidosis—Call for a New Crystalloid Fluid

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Fluid Therapy and Management

Fluid Therapy and Management

Fluid Management and Electrolyte Balance

Das Stewart-Modell

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