Stewart’s Strong Ion Theory
PTKM
[H+] x [OH-] = K1W
[H+] x [A-] = KA x [HA]
[HA] + [A-] = [ATOT]
[H+] x [HCO3-] = KC x PCO2
[H+] x [CO32-] = K3 x [HCO3-]
[SID] + [H+] - [HCO3-] - [A-] - [CO32-] - [OH-] = 0
Three independent variables determine pH in plasma
by changing the degree of water dissociation into
hydrogen ions.
Three independent variables determine pH in plasma
by changing the degree of water dissociation into
hydrogen ions.
Three independent variables determine pH in plasma
by changing the degree of water dissociation into
hydrogen ions.
The Importance of Water
H+ H+
O- O-
H+ H+
The Importance of Water
H+ H+
O- O-
H+ H+
The Importance of Water
H+ H+
O- O-
H+ H+
Hydroxide Hydronium
(OH-) (H3O+)
Strong Ions
Na+ Cl-
Strong Ions
Dissociation in water at physiological pH
Na+ Cl-
Strong Ions
Dissociation in water at physiological pH
Na+ PLASMA Cl-
Strong Ions
Water dissociates to counter resultant charges
Na+ PLASMA Cl-
Strong Ions
Water dissociates to counter resultant charges
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
Na+ PLASMA Cl-
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
Strong Ions
pH = -log [H3O+]
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
Na+ PLASMA Cl-
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
Strong Ions
pH = -log [H3O+]
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
Na+ PLASMA Cl-
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
OH- > H3O+ = basic H3O+ > OH- = acidic
Three independent variables determine pH in plasma
by changing the degree of water dissociation into
hydrogen ions.
Independent variables influence a system from the
outside and cannot be affected by changes within
the system or by changes in other independent variables.
In contrast dependent variables are influenced directly
and predictably by changes in the independent variables.
Independent variables influence a system from the
outside and cannot be affected by changes within
the system or by changes in other independent variables.
In contrast dependent variables are influenced directly
and predictably by changes in the independent variables.
[H+] x [OH-] = K1W
[H+] x [A-] = KA x [HA]
[HA] + [A-] = [ATOT]
[H+] x [HCO3-] = KC x PCO2
[H+] x [CO32-] = K3 x [HCO3-]
[SID] + [H+] - [HCO3-] - [A-] - [CO32-] - [OH-] = 0
[H+] x [OH-] = K1W
[H+] x [A-] = KA x [HA]
[HA] + [A-] = [ATOT]
[H+] x [HCO3-] = KC x PCO2
[H+] x [CO32-] = K3 x [HCO3-]
[SID] + [H+] - [HCO3-] - [A-] - [CO32-] - [OH-] = 0
[H+] x [OH-] = K1W
[H+] x [A-] = KA x [HA]
[HA] + [A-] = [ATOT] pH and [HCO3-]
[H+] x [HCO3-] = KC x PCO2
[H+] x [CO32-] = K3 x [HCO3-]
[SID] + [H+] - [HCO3-] - [A-] - [CO32-] - [OH-] = 0
SID
Charge difference between the sum of measured
strong cations (Na+, K+, Ca2+, Mg2+) and measured
strong anions (Cl- and lactate)
SID
Charge difference between the sum of measured
strong cations (Na+, K+, Ca2+, Mg2+) and measured
strong anions (Cl- and lactate)
pCO2
Partial pressure = concentration
SID
Charge difference between the sum of measured
strong cations (Na+, K+, Ca2+, Mg2+) and measured
strong anions (Cl- and lactate)
pCO2
Partial pressure = concentration
ATOT
Total weak non-volatile acids. Weak acid buffers that
participate in proton exchange - inorganic phosphate,
glubulins, and albumin
SID
Charge difference between the sum of measured
strong cations (Na+, K+, Ca2+, Mg2+) and measured
strong anions (Cl- and lactate)
pCO2
Partial pressure = concentration
ATOT
Total weak non-volatile acids. Weak acid buffers that
participate in proton exchange - inorganic phosphate,
serum proteins, and albumin
Ca++, Mg++, K+ Lactate-
A-
HCO3-
SID
Na+
Cl-
More anions (↓ SID) = H3O+ > OH- = acid solution
More cations (↑ SID) = OH- > H3O+ = basic solution
STRONG ION DIFFERENCE (SID)
The ‘apparent’ strong ion difference, [SID]a, is given by:
[SID]a = [Na+] + [K+] - [Cl-] - [lactate-]
In normal plasma, [SID]a is equal to [SID]e, the ‘effective’
strong ion difference:
[SID]e = [HCO3-] + [A-]
STRONG ION DIFFERENCE (SID)
The ‘apparent’ strong ion difference, [SID]a, is given by:
[SID]a = [Na+] + [K+] - [Cl-] - [lactate-]
In normal plasma, [SID]a is equal to [SID]e, the ‘effective’
strong ion difference:
[SID]e = [HCO3-] + [A-]
STRONG ION GAP (SIG)
Difference between [SID]a and [SID]e
SIG = [SID]a - [SID]e = AG - [A-] SIG = 0
Strong Ions
pH = -log [H3O+]
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
Na+ PLASMA Cl-
H+ H+ H+ H+
O- O- O- O-
H+ H+ H+ H+ H+ H+
OH- > H3O+ = basic H3O+ > OH- = acidic
Strong ion approach thus distinguishes six primary
Acid-base disturbances
Acidemia - ↑pCO2
- ↑ATOT (albumin, globulin, phosphate)
- ↓SID
Alkalemia -↓pCO2
-↓ATOT
-↑SID
What’s wrong with the Henderson-Hasselbalch approach?
What’s wrong with the Henderson-Hasselbalch approach?
Magnitude without mechanism.
Hyperchloremic Acidosis
Hyperchloremic Acidosis
No difference in Rx
Hyperchloremic Acidosis
No difference in Rx
Fluids and BD - best practice?
References
Ring et al. Clinical review: Renal tubular acidosis - a physico-
chemical approach. Critical Care 2005;9:573-580
Corey H. Bench-to-bedside review: Fundemental principles of
acid-base physiology. Critical Care 2005;9:184-192
Skellet et al. Chasing the base deficit: hyperchloremic acidosis
following 0.9% saline fluid resuscitation. Arch Dis Child 2000;
83:514-516
Constable, P. Hyperchloremic Acidosis: The Classic
Example of Strong Ion Acidosis. Anesth Analg 2003;96:919-22
[Link]/[Link]
