title: The early phase of critical illness is a progressive acidic state due to unmeasured anions.
abstract: OBJECTIVE
  Stewart's and Fencl's methods have recently been proposed to interpret acid-base disorders where traditional theory has proven inadequate. Our objectives were to evaluate: (1) the occurrence of acid-base disturbances in critically ill patients and their trend over the first 3 intensive care unit days, (2) whether Stewart's theory offers advantages over the traditional theory in the diagnosis of acid-base metabolic disturbances and (3) whether variables derived from Stewart's and Fencl's methods offer advantages over the traditional method to predict patient mortality.
  
  
  METHODS
  A prospective cohort study in a general intensive care unit. Blood samples were analysed for arterial blood gases, electrolytes and proteins. PaCO2, pH, bicarbonate, base excess, standard base-excess, sodium, potassium, chloride, phosphorous, calcium, magnesium and lactate were measured. Anion gap, Stewart's and Fencl's variables were calculated.
  
  
  RESULTS
  When using Stewart's method, metabolic acidosis and metabolic alkalosis were found in 92.9% and 93.4% of samples, respectively. Corresponding figures obtained with the traditional method were 15% and 18.7%. In 245 (64.5%) samples, Stewart's method revealed that metabolic acidosis and alkalosis were simultaneously present, whereas the traditional method revealed a normal acid-base status. Strong ion gap increased significantly over the first 3 intensive care unit days. Strong ion gap and lactate were independent predictors of 28-day mortality.
  
  
  CONCLUSIONS
  Metabolic acidosis by unmeasured anions is a clinically relevant phenomenon, which is correlated with mortality. Progressive metabolic acidosis may be ongoing in the early phase of critical illness despite the absence of acidaemia.
authors.affiliation: University of Brescia, Institute of Anesthesiology and Intensive Care, Spedali Civili, Brescia, Italy. benanto@tiscali.it
authors.forename: B
authors.initials: B
authors.lastname: Antonini
authors.forename: S
authors.initials: S
authors.lastname: Piva
authors.forename: M
authors.initials: M
authors.lastname: Paltenghi
authors.forename: A
authors.initials: A
authors.lastname: Candiani
authors.forename: N
authors.initials: N
authors.lastname: Latronico
mesh_terms: D000138:Acidosis / Q000097:blood* / Q000175:diagnosis / Q000209:etiology*; D000328:Adult; D000368:Aged; D000471:Alkalosis / Q000097:blood* / Q000175:diagnosis / Q000209:etiology*; D000838:Anions / Q000097:blood; D001784:Blood Gas Analysis / Q000379:methods; D015331:Cohort Studies; D016638:Critical Illness; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies
chemical_list: D000838:Anions