Acid-Base Disorders and Their Treatment. Edited by F. John Gennari, Ph.D., Horacio J. Adrogue, M.D., John H Galla, M.D., and Nicolaos E. Madias, M.D. Boca Raton, Taylor and Francis, 2005. Pages: 856. Price: $199.95.
This 856-page book has been edited by, and has contributions from, some of the best known authors in contemporary clinical acid–base chemistry. Before proceeding, however, I have several confessions: First, I work outside the United States; second, I use (standard) base excess; and third, based on the current evidence, I use the (Fencl-) Stewart approach to acid–base disorders. But before I am dismissed as an acid–base fringe dweller, I point readers to the latest edition of Miller's Anesthesia .1
In Acid-Base Disorders and Their Treatment , in the first chapter, “Acid-Base Chemistry and Buffering,” Drs. Gennari and Galla analyze the Stewart approach but conclude that the bicarbonate-centered approach, derived from the Henderson-Hasselbalch equation, “… provides all the information needed for acid-base assessment and is a far superior tool for clinical application.” The Fencl modification of Stewart's approach for clinical work (the Fencl-Stewart approach) does not get a mention. Similarly, in chapter 26, “Measurement of Acid-Base Status,” Drs. Adrogue and Madias conclude that standard base excess has “… failed to gain substantial acceptance” while they champion bicarbonate and the rules of thumb: another riposte in the “The Great Trans-Atlantic Acid-Base Debate.”
This book has very detailed analyses of many aspects of the range of acid–base disorders: respiratory alkalosis and acidosis, metabolic acidosis and alkalosis, and mixed disorders, as well as chapters on specific disorders such as lactic and ketoacidosis. Included are items that are hard to find, such as how pH and carbon dioxide electrodes work and assays for total carbon dioxide. Another highlight, particularly for critical care physicians, is chapter 12, “Toxin-Induced Metabolic Acidosis,” by Drs. Oh and Halperin. Given the central role of the kidney, the book has several chapters on renal dysfunction as well as two on the acid–base effects of renal replacement therapies. However, I think that the international appeal of this book (and others) would be enhanced if authors, editors, and publishers allowed for the fact that most laboratories outside the United States use micromoles per liter or millimoles per liter for most biochemical variables including creatinine, urea, and glucose. Further, there is no mention that many laboratories include potassium in the anion gap calculation. A discussion of the two approaches to the anion gap, with and without potassium, would have been interesting. There is, however, discussion of Figge's correction of the anion gap for decreased albumin.
The final section of the book is 17 illustrative cases that examine assorted disorders and road-test the bicarbonate rules of thumb. I would have been interested to see the authors attempt to demonstrate that bicarbonate rules of thumb are superior to standard base excess in this section, given that we are talking about robust clinical tests rather than precise physiologic experiments. To me, the rules of thumb seem remarkably hard work that provides little, if any, gain over standard base excess in bedside (or operating table side) medicine. Of the case studies, many are set in the emergency room and would lead to patients being admitted under internal medicine specialists or the intensive care unit. These case studies may appeal to anesthesiologists with an interest in the internal medicine side of perioperative medicine. One illustrative case is set in the postoperative period and discusses the role of nasogastric suctioning and metabolic alkalosis, but fails to mention how concurrent intravenous fluid therapy may affect the situation. Further, none of the case studies involve trauma, the intraoperative period, or major hemorrhage.
As an anesthesiologist, my main concern is that there is virtually no mention of the acid–base effects of intravenous fluids, particularly the hyperchloremic acidosis associated with normal saline, even though there is a whole chapter on nonrenal causes of hyperchloremic acidosis. There are now many publications on acid–base changes with intravenous fluid therapy, looking not only at saline but also lactated Ringer's solution (Hartmann's solution) and various colloids. Nor in this book is there much on acid–base disorders in resuscitation situations such as major trauma. I believe another omission, given that there are chapters such as “Evolutionary Perspectives on the Acid-Base Effects of Diet,” is no mention of hypothermia and the alkalosis seen every day with cardiopulmonary bypass and the subsequent α-stat, pH-stat debate.
I think that this book would appeal most to my mirror image: a US-based physician, using bicarbonate rules of thumb, and a bicarbonate-centered approach to disorders. The book should interest internal medicine specialists, particularly nephrologists, as well as critical care physicians. Given the highly detailed analyses of many, but not all, acid–base phenomena, I believe that this book belongs in hospital libraries. To individual anesthesiologists, I provide that often-given advice: Have a look in Miller .1
The University of Melbourne and Austin Hospital, Heidelberg, Victoria, Australia. david.story@austin.org.au
