Acid-base balance controversy. Editorial introduction

Design and representation of multivariate patient-based reference regions for arterial pH, PCO2 and base excess values

OBJECTIVES

To determine and compare the shape and location of three data sets of arterial pH, PCO2, and BE values from intensive care patients in a new acid-base chart for the purpose of deriving multivariate reference regions.

DESIGN AND METHODS

The new chart is constructed by applying a statistical technique called principal component analysis (PCA). Three different data sets, each comprised of 1500 arterial pH, PCO2, and BE values, were subjected to PCA. The 3 data sets were collected in a respiratory intensive care unit (ICU) of a University Hospital, in a general ICU of a District Hospital, and in a neonatal ICU of a Children's Hospital.

RESULTS

The outlines of the resulting charts are similar for all 3 data sets, but the representations of the three distributions in the new chart are highly dissimilar, both in shape and in location.

CONCLUSIONS

PCA can be used to derive a patient-based reference region for arterial pH, PCO2, and BE values. Furthermore, the new chart may be useful for the graphical monitoring of acid-base data because distances between consecutive observations are faithfully represented.

Base excess or buffer base (strong ion difference) as measure of a non-respiratory acid-base disturbance

Stewart in 1983 (Can J Physiol Pharmacol 1983: 61: 1444) reintroduced plasma buffer base under the name "strong ion difference" (SID). Buffer base was originally introduced by Singer and Hastings in 1948 (Medicine (Baltimore) 1948: 27: 223). Plasma buffer base, which is practically equal to the sum of bicarbonate and albuminate anions, may be increased due to an excess of base or due to an increased albumin concentration. Singer and Hastings did not consider changes in albumin as acid-base disorders and therefore used the base excess, i.e., the actual buffer base minus the buffer base at normal pH and pCO2, as measure of a non-respiratory acid-base disturbance. Stewart and followers, however, consider changes in albumin concentration to be acid-base disturbances: a patient with normal pH, pCO2, and base excess but with increased plasma buffer base due to increased plasma albumin concentration get the diagnoses metabolic (strong ion) alkalosis (because plasma buffer base is increased) combined with metabolic hyperalbuminaemic acidosis. Extrapolating to whole blood, anaemia and polycytaemia should represent types of metabolic alkalosis and acidosis, respectively. This reveals that the Stewart approach is absurd and anachronistic in the sense that an increase or decrease in any anion is interpreted as indicating an excess or deficit of a specific acid. In other words, a return to the archaic definitions of acids and bases as being the same as anions and cations. We conclude that the acid-base status (the hydrogen ion status) of blood and extracellular fluid is described in terms of the arterial pH, the arterial pCO2, and the extracellular base excess. It is measured with a modern pH-blood gas analyser. The electrolyte status of the plasma is a description of the most important electrolytes, usually measured in venous blood with a dedicated electrolyte analyser, i.e., Na+, Cl-, HCO3-, and K+. Albumin anions contribute significantly to the anions, but calculation requires measurement of pH in addition to albumin and is usually irrelevant. The bicarbonate concentration may be used as a screening parameter of a nonrespiratory acid-base disturbance when respiratory disturbances are taken into account. A disturbance in the hydrogen ion status automatically involves a disturbance in the electrolyte status, whereas the opposite need not be the case.