Fencle versus Kellum

Dr Iyan Darmawan

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 Fencle & Kellum
• Fencle-Stewart • JA Kellum

Measure the effect of UA Directly measures the amount of UA

on base excess
Values more negative than -6 mEq/L
suspect the presence of UA
BE =The amount of acid or alkali to add to a blood
sample (whole blood) in vitro to reverse the pH to 7.40,
while pCO2 being maintained at 40 mmHg.

Fencl - Stewart Approach

•measures the effect of UA on base excess
•also called BEUA
 BASE EXCESS & STEWART
– BE measured by machine (or HCO3- - 24 + 11.6*(pH -
7.4) )
– SID effect, mEq/l = A + B
• A. Free Water effect on Na+
= 0.3 x ([Na+] – 140)
• B. Corrected Cl- effect
= 102 – ([Cl-] x 140/[Na+])
– ATOT effect, mEq/l
= 0.123 x pH - 0.6310 x (42 - [Albumin])
UA effect = BE ef – SID ef – ATot ef

Story DA, Bellomo R. Strong ions, weak acids and base excess: a simplified Fencl–
Stewart approach to clinical acid–base disorders British Journal of Anaesthesia,
2004, Vol. 92, No. 1 54-60
 Fencle-Stewart

Case 1
pH 7.2/ pCO2 25/ BE -4/ HCO3- 10
Na+160 ;Cl- 102 ;K+ 5 ;Alb 3.7

– BE -4
– SID effect, mEq/l = A + B
• A. Free Water effect on Na+
= 0.3 x ([160] – 140)=6
• B. Corrected Cl- effect
= 102 – ([C102-] x 140/[160])=12.75
– ATOT effect, mEq/l
= 0.123 x 7.2 - 0.6310 x (42 - [37])=1.273
UA effect = BE ef – SID ef – ATot ef=
-4 -(6 +12.75+ 1.273)=-24.023
 Fencle-Stewart

BASE EXCESS & STEWART

SID effect (free water effect + chloride effect 19.75)

160
SID i
SID effect 19.75
142 (alkalinisasi)
HCO3-
UA UA effect
-24.023
Albumin effect Alb Alb
1.273
Na (alkalinisasi)

Na

Primary metabolic acidosis, with increased anion gap,

mixed with a metabolic alkalosis,
with full respiratory compensation
Na+ Cl-
 Fencle-Stewart

Case 2:
7.48 / 45 / +10 / 34
Na 150; Cl 102; Alb 4
(a) Free water effect:
 0.3 x (150-140) = 3
(b) Chloride effect
 102-(102 x 140/150) = 6.8
(c) Albumin effect
 (0.123 x 7.48 - 0.631) (42-[40]) = 0.578
 UA effect = 10 – [(3) + (6.8) + (0.5)] mEq/L = - 0.3
 Fencle-Stewart

BASE EXCESS & STEWART

Alkalizing effect of HyperNa+
+10  BE +9.8
150

140 HCO3-

Alb Alb

Primary metabolic alkalosis,

Nawith
+ full respiratory compensation Cl-
 Fencle-Stewart

Case 3:
7.48 / 45 / + 9 / 34
Na 140; Cl 93; Alb 4.2

(a) Free water effect:

 0.3 x (140-140) = 0
(b) Chloride effect
 102-(93 x 140/140) = 9
(c) Albumin effect
 (0.123 x 7.25 - 0.631) (42-[42]) = 0
 UA effect = 9 – [(0) + (9) + (0)] mEq/L = 0
 Fencle-Stewart

BASE EXCESS & STEWART

Alkalizing effect of Hypochloremia

+9  BE +9
140

HCO3-
Alb
102
Alb
93

Na+ Cl-
 Fencle-Stewart

Case 4:
7.35 / 35 / -4 / 15
Na 140; Cl 102; Alb 2.0

(a) Free water effect:

 0.3 x (140-140) = 0
(b) Chloride effect
 102-(102 x 140/140) = 0
(c) Albumin effect
 (0.123 x 7.35 - 0.631) (42-[20]) = 6.0071
 UA effect = -4 – [(0) + (0) + (6.3)] mEq/L = -10.3
 Fencle-Stewart

BASE EXCESS DAN STEWART

BE due to  Alb  +
6.0071
140
SID

BE due to UA- (10.3)

Alb
hypoalbuminemia Hipoalb

Na+ Cl-
 Hipoalbuminemia
pH 7.36/pCO2 46/ BE 0.96/HCO3 26
Na+ 137; Cl- 112, Alb 20 g/L; Hb 8 g /dl

Mg++ 1
Ca++ 2.2
K+ 3.5 HCO3-
25 26 SIDe
3.5 Weak acid
(Alb- 20,P- 1)
=31.5
3.2

When these patients have a normal pH and a+normal SBE and HCO3- concentration, it would seem most
Na
appropriate to consider this to be physiologic compensation for a decreased ATOT rather than classifying
137
this condition as a complex acid–base disorder with a mixed metabolic acidosis/
Cl - hypoalbuminemic alkalosis
Stewart's designation of a 'normal' SID of approximately 40 mmol/l was based on a 'normal' CO2 and ATOT
112
The 'normal' SID for a patient with an albumin of 2g/dl would be much lower (eg approximately 32 mmol/l).

John A Kellum Determinants of blood pH in health and disease

Critical Care 2000, 4:6-14

KATION ANION
SIDa = (137 + 3.5 + 2.2 +1) – 112 = 31.7 SIDe= 26 + 0.2x[20] + 1.5 x [1]
 Fencle-Stewart

Case 5 (severe sepsis):

7.42 / 35 / -1.86 / 22 ; Interpreted by H-H  normal
Catatan: Nilai K, Ca & Mg tidak ditampilkan

Na+ 140; K+ 3.5 Cl- 102; Alb 1.8

(a) Free water
 0.3 x (140-140) = 0
(b) Chloride effect
 102-(102 x 140/140) = 0
(c) Albumin effect
 (0.123 x 7.42 - 0.631) (42-[18]) = 6.7
 UA effect = - 1.86 – [(0) + (0) + (6.7)] mEq/L = -
8.56
 BASE EXCESS DAN STEWART

140
SIDe  30.84

Acidifying effect
Alkalizing effect of UA = - 8.56 of lactate  -
Alb
hypoalb  + 6.7 8.56
hipoalbumin
102

Na+ Cl-
 J.A. KELLUM
Directly measures the amount o f UA
 JA Kellum

Case 6. Patient with cardiac arrest,CPR, hypoxic encephalopathy

pH 7.55; Na+ 159 mEql/L ;K + 3.6 mEql/L; Cl- 121 mEq/L ;Ca + + 4.2
mEq/L;Mg + + 2.2 mEq/L; PO4 0.85 mg/dl; Alb 9 g/L; PCO2 29 mmHg; HCO3
25.5 mEq/L; BE 3

What is the acid-base profile of this patient?

Approach:
1. To calculate ATOT,you have to determine Pi (in mEq/L) from PO4 and albumin
converted to mEq/L by the following formulas.

Pi = (PO4 x10/30.97)x(0.309xpH-0.469)
= (0.85 x 10/30.97) x 0.309 x 7.55 -0.469) = ~ 0.5 mEq/L

Albumin = Alb x(0.123 x pH-0.631)

= 9 x(0.123 x 7.55 – 0.631) = 2.67885 mEq/L

2. Calculate SIDa = Na+ + K+ Ca++ + Mg++ - Cl = 50.6 mEq/L

3. Calculate SIDe = HCO3- + Pi + Albumin = 28.67 mEq/L
4 UA (unmeasured anion) = SIDa- SIDe = 21.92
 JA Kellum

Case 6. Patient with cardiac arrest,CPR, hypoxic encephalopathy

pH 7.55; Na+ 159 mEql/L ;K + 3.6 mEql/L; Cl- 121 mEq/L ;Ca + + 4.2
mEq/L;Mg + + 2.2 mEq/L; PO4 0.85 mg/dl; Alb 9 g/L; PCO2 29 mmHg; HCO3
25.5 mEq/L; BE 3
Ca++ 4.2
Mg++ 3.6
HCO3- 25.5
K+ 4.8
SIDe
SIDa (28.67)
(50.6)
ATOT Alb 2.67885
Pi 0.5
SIG =(UA) = SIDa –SIDe = 21.92

Na+ 159

121

Decrease in SID ~10 was due to high UA. Plasma water deficit (Na 159 mEq/L) icrease SID. Low SID
acidosis was masked by hypoalbuminemia. BE miss detection of acidosis with high UA tand interpret
the acid-base status merely as mild metabolic alkalosis.HCO3 high normal.
 JA Kellum

Case 7. Patient with multiple trauma, followed by ARDS and sepsis

pH 7.32; Na+ 131 mEql/L ;K + 4.2 mEql/L; Cl- 86 mEq/L ;Ca + + 3.6
mEq/L;Mg + + 2.2 mEq/L; PO4 4 mg/dl; Alb 8 g/L; PCO2 41 mmHg; HCO3 21
mEq/L; BE -4.2

What is the acid-base profile of this patient?

Approach:
1. To calculate ATOT,you have to determine Pi (in mEq/L) from PO4 and albumin
converted to mEq/L by the following formulas.

Pi = (PO4 x10/30.97)x(0.309xpH-0.469)
= (4 x 10/30.97) x 0.309 x 7.32 -0.469) = ~ 2.3 mEq/L

Albumin = Alb x(0.123 x pH-0.631)

= 8 x(0.123 x 7.32 – 0.631) = 2.15488 mEq/L

2. Calculate SIDa = Na+ + K+ Ca++ + Mg++ - Cl = 55 mEq/L

3. Calculate SIDe = HCO3- + Pi + Albumin = 25.454 mEq/L
4 UA (unmeasured anion) = SIDa- SIDe = 29.55
 JA Kellum

Case 7. Patient with multiple trauma, followed by ARDS and sepsis

pH 7.32; Na+ 131 mEql/L ;K + 4.2 mEql/L; Cl- 86 mEq/L ;Ca + + 3.6
mEq/L;Mg + + 2.2 mEq/L; PO4 4 mg/dl; Alb 8 g/L; PCO2 41 mmHg; HCO3 21
mEq/L; BE -4.2
Ca++ 3.62
Mg++ 2.2 HCO3- 21
K+ 4.2 SIDe
SIDa (25,454)
(55) Alb 2.15488
ATOT
Pi 2.3

SIG =(UA) = SIDa –SIDe = 29.55

Na+ 131

86

SID decreased by ~ 12 mEq/L (owing to water excess and high UA and Pi. This
acidosis was masked by alkalosis due to Cl deficit and hypoalbuminemia; HCO3 onlu
slightly decreased. Base deficit was only - 4 mEq/L Here, the severity of acidosis had