Acid–Base Balance

The body is well equipped to digest and metabolize acidic and basic foods without
jeopardizing its acid–base balance, assuming normal amounts are ingested. The use of substances
such as baking soda to treat an upset stomach should be discouraged, however, because the
baking soda can be absorbed into the blood, thereby affecting the whole body. Non-absorbable
antacids designed to treat stomach upsets and used according to directions are a better choice
than baking soda. Acids are compounds that yield hydrogen ions when dissociated in solution.
The more hydrogen ions a solution contains, the more concentrated the acid. Bases, or alkalis,
are substances that accept hydrogen ions. Acidity or alkalinity is measured by a scale called pH
for potential of hydrogen.
The pH scale ranges from 0 to 14: acids are rated 0 to 6.999; 7.0 is neutral; bases (alkalis)
are greater than 7. On the scale, 1 would indicate a strong acid, and 14 a strong base. Thus,
lemon juice at a pH of 2 is 10 times as acidic as orange juice with a pH of 3. Physiologically, a
substance is an acid or base depending on whether it will donate or accept a hydrogen ion after
metabolism in the body. For example, both citric acid in fruit sodas and phosphoric acid in colas
are classified as acids chemically, but citric acid becomes a base after metabolism in the liver,
whereas phosphoric acid is unchanged.
The action of the lungs, kidneys, and buffer systems of the body maintains the balance
between too much and too little acid in body fluids. These buffer systems minimize significant
changes in the pH of body fluids by controlling the hydrogen ion (H+) concentration.
Buffers are substances that can neutralize both acids and bases. Proteins (hemoglobin) and the
bicarbonate (HCO3–)–carbonic acid (H2CO3) system are the most important buffers in the
extracellular fluid. Phosphate (HPO42–) and proteins are two important buffers in the
intracellular fluid.

Extracellular Fluid
The normal pH of the extracellular fluid is 7.35 to 7.45.The body is continually working
to maintain the pH within this narrow range, which is slightly alkaline despite the acidity of the
waste products of metabolism. A blood pH below 6.8 or above 7.8 is usually fatal . A pH of 6.8
produces shock, coma, and respiratory failure. The symptoms of severe alkalemia are those of
hypocalcemia because at a pH greater than 7.75, not enough ionized calcium is available for
cardiac contractility, leading to death if uncorrected. Extracellular fluid contains both positive
sodium ions (Na+) and negative bicarbonate ions (HCO3 –).
When a strong acid is introduced into the fluid, a chemical reaction takes place yielding
sodium chloride (a salt), which is neutral, and carbonic acid (a weak acid). Carbonic acid breaks
down to carbon dioxide and water, which are excreted by the lungs (exhaled) and kidneys
respectively. When a strong base (alkali) enters the system, carbon dioxide and water (the two
main waste products of cellular metabolism) react to form carbonic acid to counteract the
alkaline effect of the base. The end products of this reaction are water and a weak base that does
not drastically affect the pH.

RESPIRATORY SYSTEM

The lungs help maintain pH by varying the amount of carbon dioxide (CO2) exhaled.
Retained carbon dioxide makes the body fluids more acidic because it reacts to form carbonic
acid, a source of hydrogen ions. Too much carbonic acid, or too much of any acid, results in
acidosis, a condition that causes the lungs to automatically increase the rate and depth of
breathing, eliminating more carbon dioxide and water. This respiratory response to acidosis
begins within minutes of an increase in acidity. Respiratory compensation for acidosis is 50% to
75% effective and is an extremely important component in the regulation of pH. The respiratory
system acts quickly but can eliminate only carbonic acid. The homeostatic system can be
subverted by rapid breathing caused by anxiety which triggers paresthesias (peripheral and
perioral), peripheral tetany (eg, stiffness of fingers or arms), fainting, and sometimes all of these
findings. Tetany occurs because respiratory alkalosis causes both hypophosphatemia and
hypocalcemia .
The first aid recommended for hyperventilation resulting from anxiety is breathing
through only one nostril with the mouth closed. The previous technique, breathing into a paper
bag, can lead to hypoxia.
RENAL SYSTEM

Metabolic acids, usually derived from the diet, as well as excess carbonic acid, must be
eliminated in urine. The main metabolic acid is sulfuric acid obtained from the metabolism of the
sulfur-containing amino acids methionine and cysteine. Inorganic phosphates used as food
additives (e.g., colas) may also increase the acid content of the diet. The kidney spills or retains
hydrogen, sodium, and bicarbonate ions as necessary to maintain an acceptable pH in blood. For
example, in response to acidosis, the kidneys excrete hydrogen ions and reabsorb sodium and
bicarbonate ions. Conversely, in response to alkalosis, the kidneys conserve hydrogen ions and
excrete sodium and bicarbonate ions. The kidneys initiate these actions within 24 hours but
require 3 to 4 days to compensate for changes in blood pH. Similarly, when aldosterone
stimulates the kidney to retain sodium, potassium is excreted to maintain electrolyte balance.
Neither the respiratory nor the renal systems will overcompensate to send the individual into the
opposite state.

Intracellular Fluid

The normal pH of the intracellular fluid is 6.8 to 7.0, slightly acid to neutral. Within the
intracellular fluid, organic phosphates and proteins are the most important buffers. These
substances buffer 95% of the body’s carbonic acid and 50% of other acids. Protein is the most
powerful and plentiful buffer system in the body. Of the body’s proteins, hemoglobin has the
largest buffering capacity. Thus, red blood cells have 70% of the buffering power of the blood.
This buffering capacity allows large quantities of carbon dioxide to be transported from the
tissues to the lungs, with only a small change in venous pH compared with arterial pH.
When blood contains excessive hydrogen ions, the ions move into the cells to be buffered. Then,
to maintain electroneutrality, potassium moves from the intracellular to the intravascular
compartment, raising serum potassium levels.
Water and Acid Base Balance

Water transports nutrients to cells and heat and waste from cells; provides the volume
needed to maintain blood pressure; becomes a structural component of cells and large molecules;
and serves as a lubricant, solvent, and medium for chemical reactions.

■ Of an adult’s body weight, 50% to 65% is water, 35% of it extracellular. Of an infant’s body
weight, 75% is water, 54% of this extracellular, which can be lost quickly under adverse
conditions.
■ When the kidneys detect decreased blood pressure supplying its tissues, it begins a complex
sequence of hormonal release involving the lungs, the adrenals, and the brain. The result is
constricted blood vessels that increase blood pressure and conservation of sodium and water by
the kidney that increases blood volume.
■ Osmolality measures the osmotic pressure of fluids in the body or administered to it. Fluids are
isotonic, hypotonic, or hypertonic compared with the osmolality of human serum. Hypertonic
intravenous solutions require large vessels to quickly dilute the solution, and hypertonic oral
solutions may counteract efforts to rehydrate an individual with diarrhea.
■ Within minutes of detected acidosis, the lungs help to maintain acid–base balance by varying
the amount of carbon dioxide exhaled; however, these organs are limited to eliminating carbonic
acid. The kidneys eliminate excess carbonic acid and other acids but react slowly, within 24
hours, and may take 4 days to correct acid–base imbalances.
■ The average adult gains fluids from oral fluids (1250 mL), solid foods (900 mL), and
metabolism (300 mL), which total 2450 mL in 24 hours. During the same time, fluid would be
lost through the kidneys (1350 mL), skin (550 mL), lungs (400 mL), and intestines (150 mL) to
again total 2450 mL.
■ The Environmental Protection Agency requires that all but the smallest public water systems
be tested by certified laboratories more frequently than bottled water manufacturers, with results
reported to governmental bodies. The Food and Drug Administration regulates bottled water as a
food, exempting intrastate sales and labeling for naturally occurring fluoride but mandating a
lower allowable lead level than in tap water, although at a cost of up to 10,000 times the cost of
tap water.
■ Daily weight is the single most important indicator of fluid status, but consideration must be
given to the complete clinical situation when interpreting results. The second major technique to
assess water balance in the body is an accurate intake and output record, including visual
inspection of urine color.
■ Heat exhaustion, resulting from loss of water and salt in sweat, is differentiated from
heatstroke by mental clarity; a temperature below 102.2°F; weak, thready pulse; shallow, quiet
respirations; and a cool, clammy skin. Heatstroke presents with the opposite signs, results from a
loss of body temperature regulation, and can progress to multiple organ failure. First aid while
awaiting emergency medical technicians involves salt water orally for heat exhaustion if possible
and rapid cooling of the body with water, ice packs, and fanning for heatstroke.
■ Dehydration from fluid losses can be lethal, with infants at high risk. Hyponatremia from
dysregulation of hormonal water balance or from voluntary overhydration has proved fatal.