• Andrew Durward, Shane M Tibby, Sophie Skellett, Conal Austin, David Anderson, and Ian A Murdoch.
• Department of Pediatric Intensive Care, Guy's Hospital, London, United Kingdom.
• Pediatr Crit Care Me. 2005 May 1;6(3):281-5.

ObjectiveStewart's strong ion theory quantifies unmeasured tissue acids produced following hypoxia or hypoperfusion, by calculation of the strong ion gap. Our study objectives were as follows: a) to determine the 24-hr profile of the strong ion gap following cardiopulmonary bypass surgery; and b) to compare the prognostic value in terms of intensive care unit mortality of this variable with blood lactate.DesignProspective, observational study.SettingTertiary pediatric intensive care unit.PatientsEighty-five children following surgery for congenital heart disease.InterventionsNone.Measurements And Main ResultsArterial blood samples for lactate and strong ion gap calculation were obtained at intensive care unit admission and at 24 hrs. A raised strong ion gap (>3 mEq/L) was present in 41.1% and 51.7% of admission and 24-hr samples, respectively, being elevated at both time points in 30.5%. Both the strong ion gap and lactate increased with surgical complexity, but neither was correlated with length of bypass (r = .13 and -.02) or aortic cross-clamp (r = .13 and .10). The crude mortality was 5.8% (5/85). Four of the five deaths were associated with a persistently elevated strong ion gap, in contrast to two with ongoing hyperlactatemia (>2 mmol/L). The admission strong ion gap (cutoff, >3.2 mEq/L) was superior to lactate (cutoff, >3.0 mmol/L) as a mortality predictor (area under receiver operating characteristic curve of 0.85 [95% confidence interval, 0.74-0.95] vs. 0.71 [95% confidence interval, 0.44-0.98], respectively).ConclusionsAn elevated strong ion gap occurs commonly following bypass surgery and appears to be superior to lactate as a mortality predictor.

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