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Das Stewart-Modell

„Moderner“ Ansatz zur Interpretation des Säure-Basen-Haushalts

The Stewart model

“Modern” approach to the interpretation of the acid-base metabolism

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Zusammenfassung

Bereits vor rund 20 Jahren veröffentlichte Peter Stewart seine Abhandlung über eine moderne quantitative Analytik des Säure-Basen-Haushalts [88, 89]. Folgt man seinen Interpretationen, so wird die traditionelle Lehre vom Säure-Basen-Haushalt erheblich in Frage gestellt. Das wichtigste physikochemische Prinzip, das in Körperflüssigkeiten immer erfüllt sein muß, ist das Prinzip der Elektroneutralität.

Es existieren dabei 3 verschiedene Komponenten in biologischen Flüssigkeiten, die diesem Prinzip unterliegen:

a):

Wasser, das nur in geringen Teilen in H+ und OH− dissoziiert vorliegt,

b):

„starke“, d. h. vollständig dissoziierte und damit chemisch nicht mit anderen Substanzen reagierende, Elektrolyte und körpereigene Substanzen, wie Laktat und

c):

„schwache“, d. h. unvollständig dissoziierte, Substanzen.

Peter Stewart unterschied nun strikt zwischen abhängigen und unabhängigen Variablen und beschrieb damit tatsächlich eine neue Ordnung des Säure-Basen-Haushalts. Die 3 abhängigen Variablen (die Bikarbonatkonzentration [Bic−], der pH und damit auch die Wasserstoffionenkonzentration [H+]) sind den unabhängigen Variablen vollständig untergeordnet, können sich also nur verändern, wenn die 3 unabhängigen Variablen dies zulassen. Zu den unabhängigen Variablen zählen:

  1. 1.

    der Kohlendioxidpartialdruck,

  2. 2.

    die Gesamtkonzentration aller schwachen Säuren ([A−] (Stewart nannte diese ATOT) und

  3. 3.

    die Differenz der starken Ionen (SID).

[A−] erschließt sich aus der Albumin (Alb)- und der Phosphatkonzentration (Pi): [A−]=[Alb×(0,123×pH−0,631)]+[Pi×(0,309×pH−0,469)].

Mit Hilfe der messbaren Ionenkonzentrationen lässt sich eine apparente SID (oder „Bedside-SID“) berechnen: SID=[Na+]+[K+]−[Cl−]−Laktat.

Betrachtet man die metabolischen Störungen des Säure-Basen-Haushalts, so sind nach der Terminologie von Stewart Veränderungen von pH, [H+] und [Bic−] nur möglich, wenn sich entweder die SID oder [A−] verändert. Nimmt z. B. die SID ab (etwa im Rahmen einer Hyperchloridämie), so bewirkt dieser Zuwachs an unabhängigen negativen Ladungen eine Abnahme der abhängigen negativen Ladungen in Form von [Bic−] mit dem entsprechenden Resultat einer Acidose (und vice versa). Damit wird aber beispielhaft bei der hyperchlorämen Acidose, die durch den Chloridanstieg bedingte Abnahme der SID als Ursache der Acidose identifiziert. Umgekehrt resultiert z. B. aus einer Abnahme von [A−] (etwa im Rahmen einer Hypoalbuminämie) ein Anstieg von [Bic−] und damit eine Alkalose (ebenfalls vice versa). Mit Hilfe dieser Analytik können also völlig neue Säure-Basen-Störungen, wie etwa die „hyperchloräme Acidose“ oder die „hypoalbuminäme Alkalose“ (die natürlich auch kombiniert vorliegen können), diagnostiziert werden, die der klassischen Säure-Basen-Analytik verschlossen waren. Damit kann diese Analytik zu einem vertieften Verständnis der Mechanismen, denen der Säure-Basen-Haushalt unterliegt, führen.

Abstract

About twenty years ago, Peter Stewart had already published his modern quantitative approach to acid-base chemistry [88, 89]. According to his interpretations, the traditional concepts of the mechanisms behind the changes in acid-base balance are considerably questionable. The main physicochemical principle which must be accomplished in body fluids, is the rule of electroneutrality. There are 3 components in biological fluids which are subject to this principle:

a):

Water, which is only in minor parts dissociated into H+ and OH–,

b):

“strong”, i.e. completely dissociated, electrolytes, which thus do not interact with other substances, and body substances, such as lactate, and

c):

“weak”, i.e. incompletely dissociated, substances.

Peter Stewart strictly distinguished between dependent and independent variables and thus indeed described a new order of acid-base chemistry. The 3 dependent variables (bicarbonate concentration [Bic–], pH, and with this also hydrogen ion concentration [H+]) can only change if the 3 independent variables allow this change. These 3 independent variables are:

  1. 1.

    Carbon dioxide partial pressure,

  2. 2.

    the total amount of all weak acids ([A–] (Stewart called these ATOT), and

  3. 3.

    strong ion difference (SID).

[A–] can be calculated from the albumin (Alb) and the phosphate concentration (Pi): [A−]=[Alb×(0.123×pH−0.631)]+[Pi×(0.309×pH−0.469)].

An apparent SID (or “bedside” SID) can be calculated using measurable ion concentrations: SID=[Na+]+[K+]–[Cl–]–lactate.

Regarding the metabolic disturbances of acid-base chemistry, according to Stewart‘s terminology, changes in pH, [H+], and [Bic–] are only possible if either SID or [A–] itself changes. If, for example, SID decreases (e.g. in case of hyperchloremia), this increase in independent negative charges leads to a decrease in dependent negative charges in terms of [Bic–] resulting in acidosis (and vice versa). Therefore, according to Stewart, the decrease in SID during hyperchloremic acidosis results from the increase in serum chloride concentration and is the causal mechanism behind this acidosis. Contrary for example, a decrease in [A–] (e. g. during hypoalbuminemia) leads to an increase in [Bic–] and therefore to an alcalosis (and vice versa). Thus, by Stewart‘s approach, completely new acid-base disturbances, like “hyperchloremic acidosis“ or “hypoalbuminemic alcalosis“ (which, of course, can also exist in combination) can be detected, which had been unrecognised by the classic acid-base concepts. Consequently, Stewart‘s analysis can lead to a better understanding of the mechanisms behind the changes in acid-base balance.

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  1. Klinik für Anaesthesiologie, Klinikum Grosshadern, Ludwig-Maximilians-Universität, München

    M. Rehm, P. F. Conzen, K. Peter & U. Finsterer

  2. Klinik für Anaesthesiologie, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München

    M. Rehm

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Appendix

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Rehm, M., Conzen, P.F., Peter, K. et al. Das Stewart-Modell. Anaesthesist 53, 347–357 (2004). https://doi.org/10.1007/s00101-004-0660-x

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