Traditional approach versus Stewart approach for acid–base disorders: Inconsistent evidence

Satoshi Kimura, Muhammad Shabsigh, Hiroshi Morimatsu

Research output: Contribution to journalReview articlepeer-review

19 Citations (Scopus)


Purpose: The traditional approach and the Stewart approach have been developed for evaluating acid–base phenomena. While some experts have suggested that the two approaches are essentially identical, clinical researches have still been conducted on the superiority of one approach over the other one. In this review, we summarize the concepts of each approach and investigate the reasons of the discrepancy, based on current evidence from the literature search. Methods: In the literature search, we completed a database search and reviewed articles comparing the Stewart approach with the traditional, bicarbonate-centered approach to November 2016. Results: Our literature review included 17 relevant articles, 5 of which compared their diagnostic abilities, 9 articles compared their prognostic performances, and 3 articles compared both diagnostic abilities and prognostic performances. These articles show a discrepancy over the abilities to detect acid–base disturbances and to predict patients’ outcomes. There are many limitations that could yield this discrepancy, including differences in calculation of the variables, technological differences or errors in measuring variables, incongruences of reference value, normal range of the variables, differences in studied populations, and confounders of prognostic strength such as lactate. Conclusion: In conclusion, despite the proposed equivalence between the traditional approach and the Stewart approach, our literature search shows inconsistent results on the comparison between the two approaches for diagnostic and prognostic performance. We found crucial limitations in those studies, which could lead to the reasons of the discrepancy.

Original languageEnglish
JournalSAGE Open Medicine
Publication statusPublished - Sept 1 2018


  • anion gap
  • Henderson–Hasselbalch
  • Stewart
  • strong ion difference
  • strong ion gap

ASJC Scopus subject areas

  • General Medicine


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