ArticleIntensive care medicine2009
A critique of Stewart's approach: the chemical mechanism of dilutional acidosis.
Article in Intensive care medicine, 2009. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 23 papers.
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Who cites it
23 citing papers in PubMed.
- Physico-chemical characterization of acid base disorders in patients with COVID-19: A cohort study.World journal of nephrology · 2024Article
- Commentaries on Viewpoint: Stewart's approach to quantitative acid-base physiology should replace traditional bicarbonate-centered models.Journal of applied physiology (Bethesda, Md. : 1985) · 2021Article
- The End of the Bicarbonate Era? A Therapeutic Application of the Stewart Approach.American journal of respiratory and critical care medicine · 2020Article
- Extracorporeal COIntensive care medicine experimental · 2017Article
- Assessment of renal hemodynamic toxicity of fluid challenge with 0.9% NaCl compared to balanced crystalloid (PlasmaLyteAnnals of intensive care · 2017Article
- Intravenous fluids: balancing solutions.Journal of nephrology · 2017Review
- Transient dilutional acidosis but no lactic acidosis upon cardiopulmonary bypass in patients undergoing coronary artery bypass grafting.Archives of medical science : AMS · 2017Article
- Association of Hyperchloremia With Hospital Mortality in Critically Ill Septic Patients.Critical care medicine · 2015Article
- Has Stewart approach improved our ability to diagnose acid-base disorders in critically ill patients?World journal of critical care medicine · 2015Review
- Evaporation of free water causes concentrational alkalosis in vitro.Wiener klinische Wochenschrift · 2014Article
- Acid-base changes after fluid bolus: sodium chloride vs. sodium octanoate.Intensive care medicine experimental · 2013Article
- Why is saline so acidic (and does it really matter?).International journal of medical sciences · 2013Article
- [Practical diagnostics of acid-base disorders. Part II: Complex metabolic disturbances].Der Anaesthesist · 2012Review
- In vivo conditioning of acid-base equilibrium by crystalloid solutions: an experimental study on pigs.Intensive care medicine · 2012Article
- Partitioning standard base excess: a new approach.Journal of clinical monitoring and computing · 2011Article
- Peter Stewart: reconciliation of terminology, calculations, and conclusions?Intensive care medicine · 2010Article
- Comment on: "A critique of Stewart's approach: the chemical mechanism of dilutional acidosis".Intensive care medicine · 2010Article
- The standard strong ion difference, standard total titratable base, and their relationship to the Boston compensation rules and the Van Slyke equation for extracellular fluid.Journal of clinical monitoring and computing · 2010Article
- Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control.Intensive care medicine · 2010Review
- A balanced view of balanced solutions.Critical care (London, England) · 2010Review
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Authors and funding
4 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
objectiveWhile Stewart's acid-base approach is increasingly used in clinical practice, it has also led to new controversies. Acid-base disorders can be seen from different viewpoints: on the diagnostic/clinical, quantitative/mathematical, or the mechanistic level. In recent years, confusion in the interpretation and terminology of Stewart's approach has arisen from mixing these different levels. This will be demonstrated on the basis of a detailed analysis of the mechanism of "dilutional acidosis." In the classical dilution concept, metabolic acidosis after resuscitation with large volumes is attributed to the dilution of serum bicarbonate. However, Stewart's approach rejects this explanation and offers an alternative one that is based on a decrease in a "strong ion difference." This mechanistic explanation is questionable for principal chemical reasons. The objective of this study is to clarify the chemical mechanism of dilutional acidosis.
methodsExperimental data and simulations of various dilution experiments, as well as theoretical and chemical considerations were used.
results1. The key to understanding the mechanism of dilutional acidosis lies in the open CO2/HCO3 (-)-buffer system where the buffer base (HCO3(-)) is diluted whereas the buffer acid is not diluted (constant pCO2). 2. The categorization in independent and dependent variables depends on the system regarded. 3. Neither the principle of electroneutrality, nor a change in [SID], nor increased H2O dissociation plays a mechanistic role.
conclusionStewart's approach is valid at the mathematical level but does not provide any mechanistic insights. However, the quantification and categorization of acid-base disorders, using Stewart approach, may be helpful in clinical practice. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00134-009-1528-y) contains supplementary material, which is available to authorized users.
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