Simplified Fencl-Stewart

Interpretation in Clinical Setting

Erwin Pradian
(Sejarah)
Analisa Keseimbangan Asam Basa

• CO2-bicarbonate/HCO3 (Boston) approach

– Schwartz, Brackett et al
– Henderson-Hasselbalch equation 1916
• The Base deficit/excess (Copenhagen) approach
– 1948 Singer-Hasting, Buffer Base (BB)
– 1958 Siggaard-Andersen. Base Deficit/Excess
(BDE)
• 1960, Hb into calculation, modified Standard Base
Deficit/Excess (SBE)
• 1977 Van Slyke equation to computed SBE
• Has been validated by Schlitic and Morgan
• 1977, Anion Gap approach
– Emmet and Narins
– To address the limitation of Boston and Copenhagen
• 1978, Stewart introduced the physical-chemical
approach
– 3 independent variable;
• PCO2, SID and weak acid
• 1983, Stewart-Fencl approach
• 1998, Anion Gap Corrected
– Fencl and Figge
• 2004, simplified Stewart-Fencl approach
– Story DA, Morimatsu et al
 Anion Gap
(Emmett & Narins)
Law of Electro-neutrality

UA
AG = [Na+K] – [Cl+ HCO3]
= A- + UA
A-

Measured
Cations Measured
Anions A- = weak acid (albumin, fosfat)
UA = unmeasured anion (unmeasured
Na strong anion seperti laktat, keton
HCO3-
K dan unmeasured non strong anion)
Cl
 Normal
 
AG AG = 10-15

25
Na HCO-3

145
K Cl 105

Metabolic acidosis
HCO3- 
Normal anion gap acidosis Increased anion gap acidosis
AG = 15 (normal) AG/
HCO-3 15 Other = 25 
Na Na anion
HCO-3 15
145 145
K Cl 115 
K
105
Cl (normal)

HCO3- decreases and replaced by Cl- so HCO3- decreases and replaced by anions
there is a Cl- shift :Eg. Diarrhea or other than Cl- so no Cl- shift: Eg.renal
simple gain of H+ failure and diabetic keto-acidosis
 Tapi:
Jika [A-] menurun  hipoalbumin, hipofosfatemia, AG
bisa normal pada lactic/ketoacidosis.

CORRECTED ANION GAP

Figge and Colleague

Calculated AG + 0,25 (42 – Albumin)

Kita masih menggunakan faktor dependen HCO3 dalam perhitungan,

sehingga pendekatan AG tetap akan underestimated pada keadaan
gangguan metabolik !!
 Hubungan antara SID, AG dan SIG
• Law of electro‐neutrality:

• (Na+ + K+ + Ca2+ + Mg2+) – (Cl− + lactate + other strong anions) – (HCO3− + A−) = 0
SIDa SIDe

• AG = Semua kation – Cl- - HCO3-

• SIG = SIDa – SIDe (normal = 0).
 STRONG ION GAP
Kellum JA, Kramer DJ, Pinsky MR: Strong ion gap: A methodology for exploring
unexplained anions. J Crit Care 1995,10:51--55.
SIG
Mg++
Ca++

K+ 4
SIDa HCO3-
A-
SIDe
Lactate

= [Na+] + [K+] + [Mg++] + [Ca++] - [Cl-] – [Lactate-]

= 12.2×pCO2Na
+ Cl +[PO4–]×(0.309×pH–0.469)
/(10-pH )+10×[alb]×(0.123×pH–0.631)
-

SIG = SIDa – SIDe  Normal value = zero

Jika SIG >  terdapat UA

KATION ANION
Perbedaan dgn AG  pd SIG, nilai albumin ikut dalam kalkulasi
 Modified Fencl-Stewart
(menilai asam basa bed-side)

UA = BE – SID effect – Albumin effect

– SID effect = [Na-Cl]-38

– Albumin effect = 0,25 X (42-albumin)
– If UA (+)  Kation excess
– If (-)  Anion excess
 Kasus 1:

7.25 / 30 / -10 / 14
Na 140; Cl 112; Alb 4.0

• SBE = from a blood gas machine =…

• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…

• SBE = -10
• Na–Cl effect = [Na+]–[Cl–]–38 = 140–112–38 = -10
• Albumin effect = 0.25 x [42–40(g/l)] = 0.5
• UA = -10 – (-10) – 0.5 = -0.5

Clinical interpretation :
BASE EXCESS DAN STEWART

150 7.25 / 30 / -10 / 14

140
HCO3-
Alb
112
BE akibat pe Cl-  -10
Alb
102

WD/: Asidosis metabolik karena hiperkloremia

Causal: - Pemberian Lar NaCl berlebihan
- Gagal ginjal akut
Th/: Batasi NaCl
HD/CRRT
Na +
Cl-
 Kasus 2:

7.48 / 50 / + 9 / 34
Na 140; Cl 93; Alb 4.2

• SBE = from a blood gas machine =…

• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…

• SBE = +9
• Na–Cl effect = [Na+]–[Cl–]–38 = 140–93–38 = 9
• Albumin effect = 0.25 x [42–42(g/l)] = 0
• UA = 9 – 9 – 0 = 0
BASE EXCESS DAN STEWART
7.48 / 45 / + 9 / 34

140
HCO3-

HCO3-
BE akibat  Cl-  +9 Alb

Alb

WD/: Alkalosis metabolik karena hipokloremia

Causal:
- Diuretik Lasik
- Muntah, Enterokutan Fistula
Th: NaCl 0.9%, kurangi furosemide, cairan fistel
dimasukkan lagi
Na+ Cl-
 Kasus 3:

7.30 / 27 / -7 / 18
Na 128; Cl 100; Alb 3.0

• SBE = from a blood gas machine =…

• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…

• SBE = -7
• Na–Cl effect = [Na+]–[Cl–]–38 = 128–100–38 = -10
• Albumin effect = 0.25 x [42–30(g/l)] = 3
• UA = -7 + 10 – 3 = 0
BASE EXCESS DAN STEWART
7.30 / 27 / -7 / 18

140

128
Alb

BE akibat  Na  -7

WD/: Acidosis metabolik karena hiponatremia

Causal:
- hemodilusi
- Overload cairan, fase awal shock  oligouri
Th: perbaiki shock, inotropik, HD/CRRT
Na+ Cl-
 Kasus 4 :

7.42 / 35 / 100 / -2 / 21 ; Menurut H-H  normal

Na 140; Cl 102; Alb 1.8

• SBE = from a blood gas machine =…

• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…

• SBE = -2
• Na–Cl effect = [Na+]–[Cl–]–38 = 140–102–38 = 0
• Albumin effect = 0.25 x [42–18(g/l)] = 6
• UA = -2 – 0 – 6 = -8
BASE EXCESS DAN STEWART
7.42 / 35 / 100 / -2 / 21

140
HCOHCO3-
-
3
SID  normal
24
BE astrup = - 8 + 6 = - 2 HCO -
22 3
30.7
UA = - 8 BE akibat lact  - 8
BE akibat hipoalb  + 6 Alb
hipoalbumin
102

Lactic Asidosis metabolik “masking” oleh hipoalbumin

Na+ Cl-
Terima Kasih