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Alterations of electrolytes and albumin cause metabolic acid-base disorders. It is unclear, however,
to what degree these plasma components affect the overall metabolic acid-base state in the course of
critical illness. We performed serial analyses of the metabolic acid-base state in 30 critically ill
patients over the course of 1 week. We applied a physicalchemical acid-base model and used a
linear regression model to determine the influence of sodium, chloride, unmeasured anions and
albumin on the net metabolic acid-base state. Progressive hypochloraemia was identified as the
main cause of developing metabolic alkalosis. Changes in serum chloride and unmeasured anions
were responsible for changes of 41% and 22% in the metabolic acid-base state, respectively. Sodium
and albumin played a minor role. In conclusion, chloride is the major determinant of metabolic
acid-base state in critical illness.
Keywords
. ......................................................................................................
Table 1 Changes of acid-base state in 30 critically ill patients over 1 week after admission to ICU.
Day
1
Standard Base Excess; mmoll)1
Base ExcessSodium; mmoll)1
Base ExcessChloride; mmoll)1
Base ExcessAlbumin; mmoll)1
Base ExcessUnmeasured anions; mmoll)1
)1.9
)1.2
)4.7
4.9
)1.0
2
)2.0
)1.0
)4.9
5.2
)1.1
(7.2)
(2.3)
(5.3)
(1.9)
(3.5)
3
(6.4)
(1.8)
(4.8)
(1.7)
(5.0)
0.2
)1.1
)3.7
5.7
)1.0
(6.1)
(1.4)
(5.1)
(1.7)
(4.9)
2.2
)1.0
)2.8
6.0
)0.1
5
(5.5)
(1.5)
(6.0)
(1.6)
(2.8)
2.3
)1.0
)2.0
5.8
)0.8
(5.7)
(1.5)
(5.6)
(1.4)
(2.9)
2.6
)1.1
)1.5
5.7
)0.8
7
(5.5)
(1.5)
(6.3)
(1.4)
(2.9)
3.2
)1.1
)2.1
6.0
0.2
(7.0)
(1.8)
(6.1)
(1.3)
(5.0)
Standard base excess, Base ExcessChloride (base excess attributable to changes of serum chloride) and Base ExcessAlbumin (base excess attributable to
changes of serum albumin). Base ExcessSodium (base excess attributable to changes of free water). Base ExcessUnmeasured anions (base excess attributable to unmeasured anions).
Values are mean (standard deviation).
25
20
subsets.
15
rp with
standard
base excess
10
5
Marginal R2
Partial R2
0.77*
40%
41%
0.42*
39%
22%
0.05
4%
6%
8%
4%
0
5
10
15
20
25
Day
Figure 1 Increase of standard base excess in 30 critically ill
0.308*
Base ExcessSodium
0.07*
(base excess
attributable to
changes of free
water)
Base ExcessChloride
(base excess
attributable to
changes of serum
chloride)
Base ExcessAlbumin
(base excess
attributable to
changes of albumin)
0.10**
0.04
0.09**
0.24**
0.06**
3 Fencl V, Jabor A, Kazda A, et al. Diagnosis of metabolic acidbase disturbances in critically ill patients. American Journal of
Respiratory and Critical Care Medicine 2000; 162: 224651.
4 Story DA, Poustie S, Bellomo R. Quantitative physical
chemistry analysis of acid-base disorders in critically ill
patients. Anaesthesia 2001; 56: 5303.
5 Siggaard-Andersen O, Wimberley PD, Fogh-Andersen N,
et al. Measured and derived quantities with modern pH
and blood gas equipment: calculation algorithms with 54
equations. Scandinavian Journal of Clinical and Laboratory
Investigation 1988; 48 (Suppl. 189): 715.
6 Siggaard-Andersen O, Fogh-Andersen N. Base excess or
buffer base (strong ion difference) as a measure of a nonrespiratory acid-base disturbance. Acta Anaesthesiologica
Scandinavica 1995; 39 (Suppl. 107): 1238.
7 Wilkes P. Hypoproteinaemia, strong-ion difference, and
acid-base status in critically ill patients. Journal of Applied
Physiology 1998; 84: 17408.
8 Gilfix BM, Bique M, Magder S. A physical chemical
approach to the analysis of acid-base balance in the clinical
setting. Journal of Critical Care 1993; 8: 18797.
9 Narins RG, Kupin W, Faber MD, Goodkin DA, Dunfee
TP. Pathophysiology, classification, and therapy of acid-base
disturbances. In: Arieff AI, DeFronzo RA, eds. Fluid,
Electrolyte, and Acid-Base Disorders, 2nd edn. New York:
Churchill Livingstone, 1995: 10598.
10 Galla JH. Metabolic alkalosis. In: Arieff AI, DeFronzo, RA,
eds. Fluid, Electrolyte, and Acid-Base Disorders, 2nd edn. New
York: Churchill Livingstone, 1995: 199221.
11 Madias NE, Adrogue HJ. Acid-base disturbances in pulmonary medicine. In: Arieff AI, DeFronzo, RA, eds. Fluid,
Electrolyte, and Acid-Base Disorders, 2nd edn. New York:
Churchill Livingstone, 1995: 22354.
12 Durward A, Skellett S, Mayer A, et al. The value of chloride: sodium ratio in differentiating the aetiology of metabolic
acidosis. Intensive Care Medicine 2001; 27: 82835.
13 Funk GC, Bauer E, Oschatz E, et al. Compensatory hypochloraemic alkalosis in diabetic ketoacidosis. Diabetologia
2003; 46: 8713.
14 Riley DJ, DeFronzo RS. Acute and chronic renal failure:
acid-base, electrolyte, and fluid disorders. In: Arieff AI,
DeFronzo, RA, eds. Fluid, Electrolyte, and Acid-Base Disorders,
2nd edn. New York: Churchill Livingstone, 1995: 64384.
15 Scheingraber S, Rehm M, Sehmisch C, et al. Rapid saline
infusion produces hyperchloraemic acidosis in patients
undergoing gynecologic surgery. Anesthesiology 1999; 90:
126570.
16 Waters JH, Miller LR, Clack S, et al. Cause of metabolic
acidosis in prolonged surgery. Critical Care Medicine 1999; 27:
21426.
17 Kellum JA. Fluid resuscitation and hyperchloraemic acidosis
in experimental sepsis: improved short term survival and
acid-base balance with Hextend compared with saline.
Critical Care Medicine 2002; 30: 3005.
18 Kitabchi AE, Umpierrez GE, Murphy MB, et al. Hyperglycaemic crisis in patients with diabetes mellitus. Diabetes
Care 2003; 26 (Suppl. 1): 10917.
Cl
Nacorrected Cl Nanormal =Naobserved :
Albumin is a weak non-volatile acid and so hypoalbuminaemia results in alkalosis. The base excess effect due to
albumin can be calculated as:
Base ExcessAlbumin 0:148 pH 0:818
Albnormal Albobserved :
Any change in base excess not caused by changes in
free water, chloride or albumin is attributed to unmeasured anions. Unmeasured anions include anions such as
lactate or ketone bodies. Their contribution to base excess
can be quantified as:
Base ExcessUnmeasured anions
Base Excess Base ExcessSodium
Base ExcessChloride Base ExcessAlbumin :
Thus, the final sum of all four components is:
Base Excess Base ExcessSodium Base ExcessChloride
Base ExcessAlbumin
Base ExcessUnmeasured anions :
1115