I grew up with the German approach to acid base (“no clue – ask someone else”), then learned the Boston way (with all their compensation formulas). In parallel I tried to understand the Stewart style of quantitative acid base treatment, always missing the easy rule-of-thumb calculations I so loved in the anion gap calculations. So I really enjoyed the developments of the last years, where simple formulas for the strong ion gap proved to be adequate.

I will not delve into the discussion of the pros and cons of Stewart’s “H+ is not the point of acid base”, but happily accept that the old anion gap (if corrected for albumin) and the physicochemical approach yield the same results, if by different means. Scott Weingart at emcrit.org has devised a simple algorithm to deal with metabolic acid base disturbances, that I have adopted – you can enter all that stuff into acidbase.org’s calculator.

**Labs**: BGA (Na, Cl, K, pH, pCO2, base deficit = -base excess, lactate) plus albumin- Determine the
**sum effect**of all acid base disorders:- pH < 7,35 = acidosis
- pH > 7,45 = alkalosis

- Determine the
**respiratory effect**(might be compensation)- pCO2 > 45 = respiratory acidosis
- pCO2 < 35 = respiratory alkalosis

- Determine the
**strong ion effect**: SID = Na – Cl- SID < 38 = low SID acidosis: get urinary anion gap (UAG) = urine Na + K – Cl
- fluid administration with low SID fluids (saline, D5W)
- renal tubular acidosis if UAG > 0
- type I: urinary pH > 5,55
- type II: urinary pH < 5,55
- type IV: hyperkalemic, pH < 5,55

- SID > 38 = high SID alkalosis (nasogastric suction, diuretics, hyperaldosteronism, fluid depletion)

- SID < 38 = low SID acidosis: get urinary anion gap (UAG) = urine Na + K – Cl
- Determine the
**lactate effect**(due to hypoxia or toxicity with Metformin, Propofol, Linezolid, amphetamines, Valproate, HIV drugs, …) - Determine the
**albumine effect**: 2,5 * (4,2 – [Alb in g/dl]) - Add all the metabolic components into the
**Strong Ion Gap**:- SIG = base deficit + SID – 38 + Albumine effect – Lactate
- SIG > 2 = SIG metabolic acidosis: calculate osmolar gap = measured – 2 * Na + Gluc/18 + Urea/2,8 (> 10 is pathological)
- Uremia, diabetic ketoacidosis, alcoholic ketoacidosis
- Toxins: ASS, alcohols (methanol, mannitol, propylene glycol as in benzo or dilantin preparations), iron
- Short gut syndrome (D-Lactate)

- SIG < 0 = overdose with cations (Lithium, Bromide, Hyper-K, Hyper-Mg, Hyper-Ca, Nitrates, Immunoglobulins)

- Check adequacy of
**compensation**for chronic primary acid base disorders- In respiratory: expected delta SID = 0,4 * delta CO2
- In metabolic acidosis: delta CO2 = base deficit
- In metabolic alkalosis: delta CO2 = 0,6 * base excess

Recommended reading

- Please listen to Scott Weingart’s podcasts on acid base
- Read Kellum’s book on Stewart’s approach
- There is an excellent Swiss summary of the Stewart controversy and all the above in this German language review.