title: Comparison of three different methods of evaluation of metabolic acid-base disorders.
abstract: OBJECTIVE
  The Stewart approach states that pH is primarily determined by Pco2, strong ion difference (SID), and nonvolatile weak acids. This method might identify severe metabolic disturbances that go undetected by traditional analysis. Our goal was to compare diagnostic and prognostic performances of the Stewart approach with a) the traditional analysis based on bicarbonate (HCO3) and base excess (BE); and b) an approach relying on HCO3, BE, and albumin-corrected anion gap (AGcorrected).
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  A university-affiliated hospital intensive care unit (ICU).
  
  
  METHODS
  Nine hundred thirty-five patients admitted to the ICU.
  
  
  METHODS
  None.
  
  
  RESULTS
  The Stewart approach detected an arterial metabolic alteration in 131 (14%) of patients with normal HCO3- and BE, including 120 (92%) patients with metabolic acidosis. However, 108 (90%) of these patients had an increased AGcorrected. The Stewart approach permitted the additional diagnosis of metabolic acidosis in only 12 (1%) patients with normal HCO3, BE, and AGcorrected. On the other hand, the Stewart approach failed to identify 27 (3%) patients with alterations otherwise observed with the use of HCO3-, BE, and AGcorrected (16 cases of acidosis and 11 of alkalosis). SID and BE, and strong ion gap (SIG) and AGcorrected, were tightly correlated (R2 = .86 and .97, p < .0001 for both) with narrow 95% limits of agreement (8 and 3 mmol/L, respectively). Areas under receiver operating characteristic curves to predict 30-day mortality were 0.83, 0.62, 0.61, 0.60, 0.57, 0.56, and 0.67 for Sepsis-related Organ Failure Assessment (SOFA) score, SIG, AGcorrected, SID, BE, HCO3-, and lactates, respectively (SOFA vs. the rest, p < .0001).
  
  
  CONCLUSIONS
  In this large group of critically ill patients, diagnostic performance of the Stewart approach exceeded that of HCO3- and BE. However, when AGcorrected was included in the analysis, the Stewart approach did not offer any diagnostic or prognostic advantages.
authors.affiliation: Servicio de Terapia Intensiva, Sanatorio Otamendi y Miroli, Buenos Aires, Argentina. arnaldodubin@speedy.com.ar
authors.forename: Arnaldo
authors.initials: A
authors.lastname: Dubin
authors.forename: María M
authors.initials: MM
authors.lastname: Menises
authors.forename: Fabio D
authors.initials: FD
authors.lastname: Masevicius
authors.forename: Miriam C
authors.initials: MC
authors.lastname: Moseinco
authors.forename: Daniela Olmos
authors.initials: DO
authors.lastname: Kutscherauer
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ventrice
authors.forename: Enrique
authors.initials: E
authors.lastname: Laffaire
authors.forename: Elisa
authors.initials: E
authors.lastname: Estenssoro
mesh_terms: D000137:Acid-Base Imbalance / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology; D000368:Aged; D000418:Albumins / Q000032:analysis; D000838:Anions / Q000032:analysis*; D019540:Area Under Curve; D001639:Bicarbonates / Q000097:blood*; D005260:Female; D006801:Humans; D006863:Hydrogen-Ion Concentration; D034141:Hypoalbuminemia / Q000150:complications; D007362:Intensive Care Units; D019344:Lactic Acid / Q000032:analysis; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality; D011379:Prognosis; D011446:Prospective Studies; D012016:Reference Values; D018805:Sepsis / Q000150:complications / Q000401:mortality
chemical_list: D000418:Albumins; D000838:Anions; D001639:Bicarbonates; D019344:Lactic Acid