Transcript for:
Changes in Body Fluid Volume and Osmolarity

now we are going to talk about the changes in body fluids volume and osmolarity the changes in body fluid volumes and osmolarity in different clinical situation we'll take different clinical situations and we will observe and explain what changes occur in body fluid volumes and their osmolarity let's start with a very simple situation that let's suppose we give a person isotonic saline it's a little reputation but it's worth it suppose this is the normal you remember our basic diagram right and here it is yes plasma what is this interstitial fluid together they are exertion fluid and here it is intracellular fluid and don't forget your friend what is this red blood cell there right and of course there are proteins also now the first situation I will explain that when normal saline is given to a person right isotonic saline infusion your clinical situation is o tonic say line infusion intravenously of course right so we are adding to this system of this person isotonic saline solution in isotonic say line solution what is the osmolarity of the step number one is we have to understand what happened to extracellular fluid so what is what is the fluid coming osmolarity is 300 what is the osmolarity of normal SSL fluid 300 what is the similarity of normal intracellular fluid 300 so when you are running running intravenously normal saline or isotonic Saline now actually in every drop of saline the sodium chloride is present in such an amount that osmolarity of this drop of water of saline and essential of fluid is same right so we say solute will be added plus water will be added to extracellular fluid now do you think there will be any change in osmolarity of extracellular fluid no so step number one is that osmolarity will remain same osmolarity will remain the same it will not change is that right but volume is added is volume added or not so excess solar fluid volume will expand so osmolarity will remain same but external fluid volume will be expanded because osmolarity remain the same in the extracellular fluid and intracellular fluid will there be any fluid shift no because when we have added isos molar saline solution volume of the extracellular fluid will expand but osmolarity of the accessor of fluid will not change so this bar will remain at its the same position but volume will expand and because polarity is still even after that fair similarity of accessible upload remain 300 so there is no fluid shift at all so the new situation will be that we will say that intracellular fluid resolarity and extracellular fluidoscorality remains same intracellular fluid volume does not change but extracellular fluid volume changes Amic layer during this so this is you will write down step by step number one what was the change addition on addition of yes ISO tonic solution to extra cellular fluid spine number one this will lead to extra cellular fluid volume expansion number three no change and just extra cellular fluid osmo clarity so no fluid shift yes please fluid shift in between which two compartment no flow chip in between intracellular fluid and extra solar fluid compartments is that right Point number five this is now you have to be careful about this point when extracellular fluid volume will increase what will happen to hematocrat now you have to tell me first what is hematocrit hematocrit metocrators yes who will explain it matter crit is the volume of listen matter Critters the volume of the blood occupied by red blood cell for example look this is blood right suppose this is one liter blood all this is one letter blood now how much percentage of this blood is occupied by volume of red blood cells suppose these are red blood cells these red blood cells settle down right let's suppose out of one letter one letter is one thousand ml out of 1000 ml blood 400 ml is the volume of red blood cells remaining of plasma so what will say hematocritis 400 rather extra it is in percentage so it is 0.4 so what is a hematocrit hematocritis the percentage of percentage of blood volume right which is occupied by red blood cells those are right so let's suppose here you can say out of one liter if you measure in litter it is 0.4 liter so metacrit is 0.4 but if your half of your blood volume is occupied by red blood cell then metopritus 0.5 if you are very much anemic and point one third of blood volume is occupied by rbc's metacritis 0.33 hematocrit depends on how metal plate changes now this is very important concept how hematocrit changes if your plasma volume become more metabolic will become less if plasma volume will become less hematocrit will become more so it means whenever external fluid volume will change hematocrit may change depends on number one yes extracellular fluid what Volume Plus it also depends on volume of red blood cells listen now carefully I will draw a diagram again to show you some hematocratic changes this is a container with your blood your blood is up to here right this is suppose normal situation and this much is suppose occupied by rbcs this is by the rbcs right now suppose here it it is 40 percent of the total blood 40 percent of the total blood is occupied by red blood cell mass or red blood cell volume so we can say hematocritis let's suppose 0.4 is that right out of 1.4 is red blood cell mass now listen how hematocrit can change if you reduce the volume if you increase the volume then hematocrit will become if you increase that extra solid fluid volume and plasma volume metocrits was for 0.4 out of this situation but if it is more then it is not 0.4 it will become less so whenever extracellular fluid volume increases of course then plasma volume also increases hematocrit become less but if extrasound of fluids shrink then plasma also total blood volume also shrink so whenever blood volume shrink reduces to down metocritable increase am I clear no problem into this that whenever blood volume increases and RBC volume Remains the Same hematocritable decrease whenever total blood volume decreases but RBC Mass Remains the Same metacritable increase another way to change hematocrators keep the blood volume same keep the blood volume normal but if rbcs swell up they become larger hematocritable increase and if blood or volume is same but RBC is shrink down hematocritable decrease so listen carefully normal person has hematocrit of about 0.4 to 0.5 that 40 to 50 percent of your blood volume is occupied by red blood cell volume or mass am I clear whenever excess one way to change the hematocrat is change the exercise fluid volume other way to change the hematocrators alter the total red blood cell volume is that right no problem okay keeping this basic concept in your mind let's come back we were talking about when isotonic normal saline is added to a patient right we said extracellular volume will increase but osmolarity of external fluid and intercellular fluid will remain same and there is no shift in between these two fluids and what will happen to hematocrat normal say line will increase the volume in exercise fluid so blood volume will also increase and hematocrit will go down so hematography in this patient as less Point number six is about plasma proteins plasma proteins will become concentrated in this patient blood or diluted diluted because blood volume is increased so when you take 5 ml sample plasma protein concentration will be reduced and hematocrit will be also reduce you know why it is so important to know that if you are given two someone come to you and his body fluids are less and you give two letters of normal saline to him after some time you take blood sample and you find his RPC metacrit is less don't think it is anemia it is delusional situation are you understanding and even if you take blood sample this plasma protein concentration will be also less so you will not be fooled by this finding are you understanding me that there has been accessible volume expansion due to that hematocrat is apparently less and plasma protein concentration is less but amount of total RBC will be the same as it was previous it may not be anemia or it may be delusional anemia is that right am I clear now we come to another person we have another okay when we have a patient with isotonic say line infusion we say patient has isosmotic volume expansion what is this patient is having ISO osmotic yes volume expansion that is extra solo volume has been expanded without any change in osmolarity is that right now we go to another situation and you have to use your own brains and figure out the situation let's suppose this is the normal situation for that person now this person has a trouble you see patient number one was a patient in which isotonic fluid was added this is a patient in which isotonic fluid is lost and will compare both things question number one was where isotonic fluid was added to his body this is going to be a patient in which isotonic fluid has been lost when I say there's isotonic fluid loss it means out of the body fluid has gone out but the fluid which went out was having what osmolarity 300 millius mole per liter so the fluid which went out that has what with solute the same ratio as in extracellular fluid now under what circumstances will lose isotonic fluid out of the body under what circumstances we can lose the water and solute both classical situation is yeah oh my God he's saying sweating my friend in sweating will lose water more than the solute so this sweating is not this situation I'm talking about a clinical situation in which you lose the fluid out of the body along with the solute in as ISO a smaller fluid loss right and this ISO isos molar fluid loss is classically diary and vomiting you know when there is diarrhea you lose the fluid with solute and when you vomit out you lose the fluid with solute so let's suppose your patient has your patient has diarrhea explosive diarrhea or he has vomiting or both situation patient does diarrhea or vomiting he is losing the fluid with solute is that right R another isotonic losses that your kidney is making urine lesson kidney is making urine and urine osmolarity is the urine osmolarity is the same as blood osmolarity it means kidney is making isotonic urine remember kidney has capability to concentrate urine urine or dilute urine when I say kidney is concentrating urine it means you are passing the urine which is hyper or smaller than your blood and if I say kidney is diluting urine it means kidney is passing urine which has less osmolarity than blood but if I say or if I say kidney is making you are having the urine which is hypertonic it means kidney is concentrating the urine if I as compared to the blood and if I say you are passing hypotonic urine it means you are passing diluted urine kidneys diluting the urine and if I say you are having the urine or your patient is passing lot of urine from many hours and osmolarity of the urine is same as your blood he is passing ISO a smaller urine or he is passing ISO tonic urine let's suppose this is ISO tonic urine if your patient is passing out isotonic urine it means you are losing the fluid out of the body with the same amount of solute concentration of solute as it is in extracellular fluid so when you are vomiting or when you have diarrhea or when you are passing isotonic urine right you are having isotonic fluid losses even in Hemorrhage someone get a roadside accident he loses half liter of the blood so in the blood he is losing the volume with the same 300 Milli or small fluid is that right so all what are the conditions in which you can have ISO tonic fluid loss yes you can tell me about vomiting yes diarrhea yes I saw tonic urine and what a what was that Hemorrhage bleeding or hemorrhage all these conditions you are losing isotonic fluid out of the body when this fluid is isotonic fluid is lost from extracellular compartment you know fluid does not come directly out of cell fluid which is lost usually vomiting actually these are the gastric secretions which are coming into git right in the same way in diarrhea there are a lot of body secretions and content of the GI which are lost into urine uh sorry in the fecal matter right now so actually when there's vomiting or diarrhea or urine isotonic urine or there's bleeding the fluid is primarily coming from extracellular compartment when this fluid is lost volume of the fluid will increase or decrease so from here we'll talk about volume will decrease so it should become like volume is decreased right extracellular volume is decreased right what will happen to the osmolarity of the extracellular fluid no change it is just like that you have five liter lemonade lemonade and you bring one letter out do you think remaining osmolarity will change no you're not understanding okay if you make some salty water five liter salty water you bring one liter out of that the remaining water will remain same salty or more or less same it's so simple that when isotonic fluids come out they're bringing the solvent and solute in the same ration ratio out as it was originally present so remaining fluid will have the same osmolarity so osmolarity in the exercise of fluid will remain the same as intracellular fluid right so do you think osmolarity will change here no so extracellular fluid volume will become less but extra cellular fluid osmolarity will not change and when extracellular fluid osmolarity will not change will there be any fluid shifts in between no so what will happen intracellular fluid will remain the same industrial fluid volume and Interstellar fluid volume and osmolarity remain the same but extra solar fluid volume will become less and osmolarity will remain same so there is extracellular fluid contraction or expansion contraction so this is a situation and this volume contraction is without any change in osmolarity so we'll say there's ISO osmotic volume contraction what is this ISO a smart Tech yes volume contraction now I'll make it rapidly and you have to tell me if this is a patient these are two patients and in this person now listen carefully this person's this is a change and in second person this is a change a patient and patient number one and patient number two in both cases osmolality has not been changed this is isotonic isosomotic this is Alpha isosomotic but here volume has been expanded and here volume has shrankan so what will be this ISO osmotic volume expansion isoscemotic volume contraction is that right remove it look at and review this in this case this is isosomotic but volume expansion here is still isosmotic but volume contraction so whenever you add isotonic fluid to the body body will have isoscemotic volume expansion whenever you remove isotonic fluid out of the body there will be isos motive volume contraction this is difficult easy should we move to the next example right now we will come to another situation this time we will add or remove yes salt out of the body let me tell you one thing in this situation we were adding salt and water both here we were removing salt and water both is that right or we can say here we were adding solute and solvent both here we were removing solute and solvent work now we'll take two more patient example patient number three and patient number four in patient number three we will add mainly salt and in patient number four we will mainly remove salt out of the body we'll see what happens right now we go to the patient number three and patient number three suppose this is the situation here normal right you understand it so well now this is a normal situation of course what is here blood but before really I go to three we did not talk about here about rbcs did we what happened to rbcs when there is isosmotic volume contraction so blood volume become less and whenever blood volume become less a metacrit will go but RBC is a lot shrink or swell because of similarity is not changed so in this case we should also discuss okay let come let's come back to this what was happening the addition of traditional loss of sorry there was loss of loss of ISO tonic solution from the body that will lead to volume contraction in an extra cellular fluid and no osmolarity change no fluid yes shift but because because there is increased because there is decreased extra cellular volume so hematocrit will increased and rbcs will swell or not RBC no swelling no swelling no shrinkage because osmolarity is not changing right and plasma protein will get plasma protein will get on sun rated am I clear this ISO osmotic but it is written like this Right iso or smart Tech yeah isoscemotic right so any question about these two situations there is no now we come to the next situation let me repeat again in patient number one and two we have added here we have added isosomotic fluid here we have added removed isoscemotic fluid out of the body in this case we added the water with solute here we removed water with solute now we come to third patient in third patient what we do now listen carefully in third patient what we are going to do okay remove this situation what we are going to do that we add salt sodium chloride more to the body as compared to the water what are these situations for example if we give you salty potato chips you eat lot of salty potato chips or I give you hyper tonic fluid you understand hyperton hypertonic fluid I'm giving from intravenously fluid which has osmolarity more than 300. such fluid may be saline when there is hyper or smaller saline solution or there may be fluid with many tall many taller also special particle we add to the fluid and make the fluid more or smaller than 300 so we are giving hyperosmolar manitol or we are giving hyperosmolar Saline or you are eating lot of salty hyper salted potato chips or somehow I don't know for some reason you have taken the tablets of sodium chloride under all these circumstances you are adding solute more than the solvent to the body fluids in all these conditions what you are adding more solute are more than the water is that right so under these circumstances when hypertonic fluids are there or protect so what happens this area become hype hyperosmotic or hyperosmotic hyperosmotic that's sodium chloride concentration or many tall concentration or whatever fluid which you have added with a lot of solutes very very concentrated fluid this become highly concentrated extracellofloid under these circumstances originally it was having 300 Milli or small and this will become maybe three 60 Milli or small are you understanding so what we have done we have patient as person has gone through some situation in which this extracellular fluid has become hyper or smaller now what will happen osmolarity will go up when osmolarity will go up right because many tall cannot go here sodium chloride cannot go here so hyperosmolar solute part solute particle will concentrate in extracellular fluid now osmolarity of extracellular fluid is more than intracellular so what will happen fluid will shift from intracellular to accessor compartment so intracellular compartment will start shrinking extracellular compartment will start expanding so this will move to this side and this will move to that side it is reducing its size and this is increasing its Volume Plus it it is having highest molarity so osmolarity has gone up because essential of fluid has high osmolarity when fluid is shifting from intracellular side to extracellular side fluid intracellularly also get concentrated so intracellular osmolarity also goes up so what will be the Situation Number One both compartment have high osmolarity initial highest molarity in extracellar fluid to pull the water from intracellular to access alert right and osmolarity in extracellular water is yes I will make it red osmolarity in extracellular fluid is high this is one thing secondly extracellular fluid has more volume because if you have given hypertonic fluid some volume came with that plus it has sucked the wall it has taken the volume from intercellular so it will become more volume is that right its volume will increase so it has increased its volume it has also increased its osmolality and this side has reduced its volume but as it is losing the water there its osmolality also become High so it has reduced its volume but eventually steady state will come both of them have same what possible added is that right so what has really happened what has really happened if you want a single pointer that we can put it here things have gone into this direction the whole thing has gone to that direction that when we added too much solute here right osmolality goes up and it pulls the water from this side same pointer you apply here when you added isotonic fluid osmolality did not go up it remained the same at the same but volume went here is that right any problem in understanding this now we can write it what really happened no point number one the first changes addition of what is addition in the body addition of more solute than water that is addition of hyper yes or smaller fluid in the body is that right this is the first change second change is what is that extra cellular fluid osmolarity increase what is the fluid shape intracellular fluid shift to extracellular fluid extracellular fluid volume increase and of course intra cellular fluid volume decrease is it difficult to understand the all logical you put more solute here it become hyper cellular hyper smaller pull the water from here and it expands and it become also hyper cellular hyper or smaller Sorry by losing the water plus its volume shrink is that right and what will happen to hematocrit ocrite well decrease yes hematocrit will decrease because extracellular fluid volume is more so RBC volume relative volume of RBC will become less so metacrit will decrease due to due to increase extra cellular fluid Volume Plus metacrit will decrease also because red blood cells will shrink because if there's a red blood cell here red blood cell had 300 mil osmolarity but because of too much solute here extracellular osmolarity is high and fluid will move out of red blood cells so red blood cells will shrink and when red blood cells will shrink the volume will become still more or less and when are you understanding it you are not understanding what is happening that because extracellular fluid is hyper or smaller hyper it is more osmolarity so from the red blood cell water will go out because red blood cell has the same ocularity as other cells in the body as fluid is shifting from all the cells to the external environment fluid also shift from RBC to exercise environment so rbcs will shrink so two things happen and both things reduce the hematocrit number one because extra cellular volume has increased so metal grade become less number two red blood cell volume is decreased because they shrink by losing the water so metacarp will decrease due to increase exercise of load Volume Plus metacrit will decrease due to RBC shrinkage am I right another thing what will happen to plasma proteins exercise blood volume is extracellular fluid volume is increased so blood volume is increased but do you think plasma protein are increasing no so what will happen to plasma proteins plasma protein concentration decrease right plasma protein concentration decreases now this is a case of volume expansion of volume contraction fluid will not talk about intracellular so it's a volume expansion and what is this type of volume volume expansion this type of volume tension after salty potatoes this volume expansion is yes hyper or smaller right so we'll call it hyperosmotic volume expansion what we will call the situation hyper osmotic volume expansion now compare patient number one and patient number three attention please in patient number three there was ISO osmotic volume expansion and here it is hyperosmotic volume no problem into this so these are both cases of volume expansion is that right another thing when volume in the blood expand pressure in the blood vessel will be less or more so blood pressure also increases so these patients arterial blood pressure increase in this patient what will happen there is isoscemotic volume expansion the volume is expanded in extracellular fluid and then volume is suspended then blood volume is also more so blood volume in the same blood vessels when volume will become more blood pressure will go up you're not understanding look this is your circulatory system right this is the capacity of circulation system and this is the volume of circulatory system in this circulatory tube if you put more volume pressure on the tube will go up or down so it's like that what is this there are arteries the capillaries the veins and heart pumping this is a tube this is a tube system whenever a volume in the tube will go up pressure will go up and whenever volume is less pressure will go down we don't need any big scientists to infer this you can use your own cerebral cortex to decide it right so blood pressure in this situation will go up and here also volume has expanded what will happen to blood pressure blood pressure will go up arterial blood pressure will go up and when you are having isoscemotic volume losses and vomiting and diarrhea and what is the other thing isotonic urine formation your volume is Contracting when extra cellular fluid volume is Contracting then blood volume also contract so what will happen to blood pressure arterial blood pressure will be down is that right okay if you have really understood I will go forward but before moving forward I will draw a diagram and now you have to I'm drawing the three diagrams and you have to tell me what type of expansion or contraction is going on okay my patient has undergone this alteration what is it isosmotic volume expansion another patient has undergrown this situation what is this isosmotic volume contraction patient has undergone suspension what is this hyper osmotic volume expansion out of this situation patient number one two and three which patient has been given hypertonic solution three which patient has given isotonic solution which patient has diarrhea or vomiting now we'll come to one more situation foreign this is another patient patient number four right and in this patient number four there is very unusual situation let me explain here is your okay you know kidney has nephrons you know that or not the nephron tubes which make urine now let me tell you something actually there are some cells in distal part of the Nephron and collecting tubule of the Nephron the special cells these are called principle cells what are these cells called principles Health on these principle cell a hormone work which is called eldo steron there's a hormone aldosterone which work on the principles have this hormone come from adrenal cortex this is produced by adrenal adrenal gland cortex so adrenal gland cortex has a special area called zoonoglomerulosa this Zona glomerulosa produces aldosterone aldosterone act on the which cells principal cells and when you know fluid filter normally what happened fluid is filtered from extracellular compartment it is passing through the nephron whatever is required by the body it is pulled back and whatever is required by the body tubular cells pull that thing back to the body and whatever is not required it is allowed to go into urine is that right so what we are doing that from our blood we make some filtrate fluid filter here and filtered fluid is passing through the nephron tube and whatever is needed by us nephron cells reabsorb that and whatever is not needed that is allowed to go into urine is that right now you know sodium and chloride is very important for us because sodium and chloride should be present in extracellular fluid in sufficient amount if sodium chloride is maintained and sufficient amount in excess of fluid then extracellular fluid volume can be maintained your place normally what happens lot of sodium chloride is in this filtrate lot of sodium chloride goes down different part of the Nephron reabsorb the sodium and chloride and bring it back to the body right and in the urine very small of sodium chloride is very small amount of sodium chloride is lost are you understanding now if there's a disease in which adrenal cortex is destroyed there are two glands if both adrenal there's the right adrenal adenocortex and left you should know that this body has a right side and left side right okay just to remind you now there are two uh these adrenal glands if in both adrenal glands adrenal cortex is destroyed by some disease this disease may be tuberculosis or this disease may be amyloidosis or this disease may be hemochromat there are many diseases or autoimmune diseases so due to any reason if both adrenal gland cortices are destroyed you will have extra aldosterone or severe deficiency of aldosterone severe deficiency of aldosterone and and some other hormones of the adrenal cortex so this situation is called adrenal adrenal insufficiency in Safi CNC or in those conditions where both adrenal gland cortices are destroyed we call it Addison's disease what we call it a distance disease so in addition to this adrenal glands cortices are not working and when adrenal gland cortices are not working there are severe deficiency of adrenal cortical hormones including deficiency of aldosterone when there is deficiency of aldosterone when there's no aldosterone actually under the influence of aldosterone principle cells reabsorbed salt and reabsorb mainly sodium so it means aldosterone is a sodium retaining hormone that Elder Spherion the hormone which goes to a nephron act on the principal cell and help the principal cell to reabsorb sodium to the body is that right now imagine if Alto Serum is not there then can you recapture sodium from here no so more sodium will be lost into urine or less sodium is lost into urine if altosterone is not there principal cells are not working well can the ribs off sodium so where the sodium will go down down where to your end right so what happens that there is extra losses of sodium and chloride so urine will become what hypertonic right so this salt and there's sodium chloride losses when they are heavy sodium chloride losses right but listen there's another hormone which is called ADH what is it a d h this reabsorbs the water now water reabsorption is still good but sodium reabsorption is impaired so we are losing more solute as compared to the fluid so body is losing which thing solutes of the extracellular fluid main solution Sodium Chloride when solutes are being lost out of it my friends what will happen it will become hyper smaller or hyper or smaller hyposmolar right so you know it well that osmolarity will become less so this will become external fluid will become high power smaller when it will become hypersolar its osmolarity from 300 will become to maybe 270. when SSL of fluid is losing salt and sodium and chloride is osmolarity will become less and when it's osmolarity will become less it become hypo smaller but intracellular fluid is 300 so water will move in which direction yes water will move from exercise compartment to intracellular right so what will happen extracellular compartment will become expanded or shrunken so with lowest molality it will shrink sslr and what will happen to intracellular compartment it will shrink or expand expand and its osmolity will come down due to it because it is gaining the fluid so extracellular fluid as showing expansion with hypo osmolarity so what this news steady state is showing the new steady state in a patient who is losing too much salt sodium and chloride or hypertonic solution out of the body right classically seen in Addison's disease or adrenal insufficiency because the Elder strenone is not there so in this case now write down the step step number one is right from here step number one is yes loss of sodium chloride from extracellular yes excess alert fluid so reduce osmolarity of extracellular fluid that will result into what yes fluid shift from extracellular fluid to Ultra cellular fluid fluid is shifted right extra cellular fluid osmolarity is less plus extracellular fluid volume is less intracellular fluid osmolarity is less and volume of interstellar fluid is also that is more that is more is that right any question after this no problem right and what will happen under these circumstances what will happen to hematocrit what will happen to rbcs volume has become less successful so metacrit will go up so hematocrit will go up due to two reasons metocrat is up why number one extracellular fluid is volume is number two look when extracellular fluid has low loss molarity RBC has 300 so fluid will shift to the rbcs as fluid is shifting from the accessory compartment to intracellular compartment from the plasma also fluid shift to the intracellular area of the RPC so RBC is well swallowed so when rbcs swell up that often creases when rbcs will swell up that will also increase yes hematocrite so we can say hematocrit is increased in this person why number one SSL of fluid has become less number two rbcs have swollen is that right and what will happen to blood pressure do you think in the vascular tube their vascular tube there is a more fluid or less fluid so blood pressure will drop am I right there is no problem into this okay let's have a break so what we have learned up to now that when isotonic Solutions are added to the body fluids there is isosomotic volume expansion the volume expansion without any change in oscolarity and when ISO osmotic fluids are removed from the body like vomiting diarrhea or isotonic urine formation or Hemorrhage when isotonic fluids are lost from the body external volume extracellular fluid volume construct but without any change in osmolarity and this is called ISO osmotic volume contraction then in these two examples what we are doing here we are adding the solutes to the body this net gain of solutes and there there's net loss of solute how in this example we are giving the person hypertonic intravenous fluid or he has been given sodium chloride tablets or salty potato chips so lot of solutes are added to the extracellular fluid and extracellular fluid is getting hyperosmotic and it also pulls the water from intracellular compartment so it will become expanded so we'll call it hyperosmotic volume expansion and in that particular condition where there is adrenal cortical insufficiency there is deficiency of Elder steron and when there is deficiency of aldosterone salt and sodium and chloride cannot be retained well so there's excessive losses of sodium and chloride so there's a net loss of solute from extracellofloid so extracellular fluid become hypo or smaller and fluid shift from extracellular compartment to intracellular compartment and this must be called hypo or smaller volume contraction so we should write here there is hypo or smaller volume contraction right now it's so easy to understand isotonic fluid added isotonic fluid removed solutes added solutes removed what should be logically Next Step relatively water added to the body water removed is that right now we'll talk about those two conditions let's suppose we have another patient patient number five right and in this patient foreign to drink two one liter of water right when he is taking drinking one liter of tap water it means water is entering in body more as compared to the solute tap water is high postmodate right so now we are adding to the body relatively yes water right now when you are adding water what are the circumstances this may be done when someone drink lot of tap water or someone is given half normal saline half normal saline mean that solution is hyper tonic is that right or another situation in which this can occur that is syndrome of inappropriate ADH secretion right what is this syndrome of inappropriate ADH secretion you know ADH hormone is normally produced normally released by posterior pituitary gland but sometimes ADH levels in the body may be produced in excessive amount inappropriately for example someone have a cancer of lung someone has a cancer in the lung and if cancer cells are producing too much ADH we will say this is syndrome of inappropriate ADH secretion because normally area should not be secreted by cancer cells so if anyone has excessive amount of ADH in his body what will happen ADH is antidisuretic hormone so one way to add the water to the body is tap water other is that if your body has excessive amount of what is this ADH antidiuretic hormone now what is the function of antidiuretic hormone normal function of antidiuretic hormone is that from the last part of the Nephron it reabsorbs water let's go to that diagram you know I told you here aldosterone mainly ribs are sodium and chloride and your ADH mainly ribs are water in this additions to these they were deficiency of aldosterone and they have a waste of salt and now the condition which I'm talking about there is excessive amount of ADH and when there is excessive amount of ADH too much water is reabsorbed from last part of nephron from the collecting tubules is that right from the ADH sensitive cells now when anti-diuretic hormone level in your body is very high you are absorbing too much water from the Nephron it means you are not losing enough water into urine right you are losing the solute but not water so this is equivalent to adding the water pure water towards your extracellular fluid so how you can add extra cellular fluid with the excessive water with less solute one way is drink lot of drink lot of tap water otherwise patients who have high concentration of antidiurotic hormone they absorb too much water number three is give someone hypotonic Solutions when you give hypotonic solution water amount is far more excess than the solute so under all these circumstances extracellular fluid osmolarity will go up or down when yes when you are drinking too much water this is becoming diluted or concentrated diluted or if ADH is absorbing too much water again it is becoming diluted or when you give hypotonic Saline again you are making this area diluted so what will happen it's a it will become 270 osmolarity will drop when osmolarity in this area will drop what will be the movement of water yes when extracellular fluid osmolarity will drop water will move from excessive fluid to intracellular but listen now carefully what was the change number one osmolarity of extracellular fluid dropped so it came here is it right volume of extra solar fluid was expanded volume as a social fluid expanded because water is coming in the form of hypotonic saline or water is coming from git or water is inappropriately reabsorbed from nephron through extra amount of anti-diurotic hormone so extra amount of water coming through extracellular fluid number one volume expand number two because water is coming more and solutes are less so osmolality drop and when this area become a high post molar what will happen that water will shift from where extra cellular fluid to intracellular fluid and intracellular fluid will also get diluted so extras intracellular fluid will get expanded plus it will also get diluted because it is receiving the water so what is happening extracellular fluid yes extracellular fluid expansion is there but extra cellular fluid expansion is there with high pose molarity so this condition will be called hypo smaller what is this hypo smaller volume expansion hypos molar volume expansion is that right any question after this per square now what will be the other changes for example what will be the change in hematocrit what will be the change in hematocrat metocrat now hematocrit depends on number one extracellular fluid volume so when extras cellular fluid volume is more so hematocrat will become less metocrators will become less but another thing what will happen to rbcs what will happen to RBC swell so swelling off swollen rbcs and hematocrit goes up so actually there will be opposing effect on the hematocrat that because extracellular fluid is hypo or smaller so rbc's will reabsorb our rbc's will absorb the batter so rbcs will swell up so volume of rbcs will increase but at the same time exercise fluid has also increased both of them increase in same ratio within hematocrit will alter no so there's no change in a Battleground let me repeat it again listen we said previously whenever extra cellular fluid increase hematocrit become less does that right but here even though extracellular fluid is increasing but at the same time rpcs are swelling and RBC volume is also increasing so both of them increase in the same ratio so result is a matter of Greater domain normal but prote plasma protein concentration will be diluted less okay this was one condition now we come to another condition and wait let's go to the next patient another patient right and in this patient patient number six let's suppose it's your friend and he has gone to Arizona desert and somehow he is lost his lost there and he doesn't have any water with him and he's not he has not found any water source so he's sweating and sweating and sweating right and not drinking water so if you are sweating if your friend is sweating so heavily example is sweating in desert without water sweating in desert without water right or when you are sweating you are losing the fluid there will be volume contraction is that right but in the sweating water is lost more than the solute because humans sweat is a high Force molar human sweat is having osmolarity less than 300 so as he keep on sweating water is being lost more than more than solute this is your one friend other friend of you has high grade fever you have another friend in your hometown and he has very high grade fever from many hours when you have hybrid fever water is evaporating from your body and also from respiratory you know uh people who have high grade fever they bring the air out which is very humid and losing the water in that but do you think they are losing as much solutes also no so person who has high grade fever is also losing water relatively more than the solute and person who is sweating he is also losing water more than the solute and another person which can lose water more than the solute is a person who has deficiency of ADH antidiuretic hormone that situation is called diabetes insipidus it is not diabetes mellitus this is diabetes insipidus in diabetes insipidus what really happens that there can be two types of problem either there is no ADH no idea to work here so water is not coming back because you know it anti-diurotic hormone work on the last part of the Nephron and reabsorb water if there is no ADH then water is lost into urine too much urine become hypotonic hyposmotic too much water is lost which should be resolved right or ADH is there but last part of the Nephron are dysfunctional and they are not responding to Idiot still you are losing a lot of water so if there's no ADH we call it cranial cranial diabetes insipidus cranial diabetes inhibitor and which is there but kidney nephrons are not responding to ADH we call it nephrogenic nephro genic diabetes inseparatus so there are three condition I'm mentioning in which you are losing hypo tonic water out of the body when I say that you are losing hypotonic or hyposmolar water it means water is low lost far in excess than the solutes of the body classical example that excessive sweating without replacement of water sweat is hypotonic in the fewer you lose the water with less solute and in diabetes insipidus you lose water with less solute so body develop water deprivation is that right now in this case when water is being lost from extracellular fluid extracellular fluid will have volume expansion or contraction so number one volume will be in contraction to this side number two it will become external fluid will become concentrated or diluted concentrated so it will become hyper or smaller so in V all these condition person who is sweating too much or having high grade fever for a long time or having diabetes insipidus is losing an excessive water out of the body so excess and a fluid become hyper smaller sorry it become hypovolemic with Hyper or smaller because water is lost but solutes are not lost am I right now normally suspolarity was 300 now it has become 340 when accessible fluid become hyper or smaller what will be the fluid shift from yeah what is this intracellular to extra cellular right and when this fluid shift will there as intracellular compartment will also become hyper volumic it will also shrink intracellular compartment will also shrink and when it is losing more water on the extracellular side it will become concentrated and hyper or smaller so this is a situation when someone is sweating too much or someone who is losing hypertonic urine or someone who is having high grade fever for long time initially go step by step step number one person who loses lot of water from extracellular compartment then extracellular compartment fluid become hyperosmolar so extracellular compartment when it becomes hypo smaller hyper or smaller sorry it's increasing hyper or smaller then fluids shift from Interstellar compartment to extracellular compartment so intracellular compartment also shrink is that right so exercise compartment or initially shrank and later on when hyperosmolarity was there in extra solo compartment intra solar compartment also shrink become hyper or smaller is that right so in these patients there is yes hyperosmolar volume contraction so what we'll write here hyper yes or smaller yes volume contraction there is hyper or smaller volume contraction am I clear there's no problem up to this now in this situation what will happen to hematocrit hematocrit mean the volume of the blood which is occupied by rbcs actually apparently because extra extra cellular fluid compartment shrink so we think that a matter of creature increase no we should when whenever it construct rbcs are there but extra solar compartment shrink so we think apparently that hematode should go up but because fluid is hyper cellular it's pull the water out of rbcs and RBC shrink this is the right when RBC is shrink so a metacrid should go down so there are two things happening same time extra solar fluid volume is shrinking as well as RBC is shrinking so both of them cancel each other and there's no change in hematography am I clearer I should write it there you are really clear and surprised right so in this case hematocrit will remain the same even though shrinkage of the volume should increase on autocrate but RBC is also shrink come here in this case when to my water was added to SSL of fluid a metal crate should decrease because volume is expanded but rbcs also swell up so it remains stable but you come to these two situations here a Metro Credit what happened to hematography here what is this hyperosmotic volume expansion when hyper osmotic volume expansion is there volume expand a matter of fracture decrease no matter the pressure decrease so metal decreases because volume expands plus metabolic also decreases because yes sharing is that right there is double decrease in a matter of grade here no matter what will happen to hematocrat when volume shrink a metal grid should go up at the same time R which is swell so both of them lead to increased metocrat because you know fluid is hyposmolar and fluid will come out of uh what is this because fluid is hyper smaller right so rbcs will absorb the water and they will swell up so here fluid is fluid is shrinking and rbcs are swelling so metal grid will be yes hi in this case let's come back here fluid volume increased but no change in the volume of rbcs so metacorate will decrease here fluid isotonic fluid contraction so fluid construct but no change in the rbcs volume metabolic will go up am I clear there's no problem in this if you have understood all of this I will just make a small test for you right now Let's see we have really learned something or not right look this is the original situation right I will make a multiple situations and we will see what is there these are multiple different patients in this case the change okay I'll make it blue color now the changes yeah what is there isotonic volume expansion and there is a change there's isotonic volume contraction okay and there is a change what is it hypertonic volume expansion and there is what is it hypertonic volume contraction hypotonic volume expansion okay what is it hypertonic volume contraction okay that's done now I will do another test with you I will give you choices what's wrong there this is a situation right and patient has let's suppose what what is this condition you will recognize as hyper tonic volume contraction this situation may result I will give you choices a b c d e okay it is sweating or it is diarrhea it is adrenal in sufficiency or it is sweating diarrhea renal insufficiency fever okay rather than fever we can say that uh hyper tonic fluid infurian furion and here the renal insufficiency and there one more situation we can put like tell me some pathological situation which may affect the volume Hemorrhage okay Hemorrhage bleeding right produce the same type of situation okay we put these four out of these four this is presenting which situation there's a hypertonic volume contraction adrenal insufficiency is a wrong answer because in adrenal insufficiency there will be reduction in the volume right salt is lost and that is hyposmolar as well in adrenal insufficiency you're losing the salt so you are losing the volume and you are losing the salt that will be high pro smaller but this is hyper or smaller look let's just a minute volume has been reduced think clinically volume has been reduced and it has become concentrated so from here what is really lost water so this is a water losing condition hyper smaller fluid is lost where hyper smaller fluid loses sweating so here the answer is a for this situation we'll make one more just a practice okay we've made another choice uh tab water drinking in large amount now uh what we can say that it is High post molar situation and hypovolemic yeah this is the situation now think logically first volume has been reduced osmolality is also down what does it mean what is really lost out of the body what is loss solutes are lost because too much solutes are lost so it has gone down and because solutes are less the water shifted to the side so this is solute wasting situation what is this solute wasting situation you remember on the kidney there was a hormone working and reabsorbed solute ADHD ribs or water adrenal and sufficiency am I right let's make another situation now look osmolality has become less and volume has been increased it means what is added to this water is added which is having less solute so what do you think tap water are you understanding me tap water has been added that is why volume has become more accessibility and osmolarity has become less right now I'll make one more situation for you so what is the answer here e and other like this and and is it possible now it can be like this but this we have already discussed there let me find some more situation okay I'm going to make another situation and you have to answer me rapidly volume has been increased without increase in osmolarity so what is the isotonic fluid has been added where is isotonic fluid there is sweating there is diarrhea there is oh my God we have to add one then f f is for f uh what we are adding isotonic fluid infusion so it means you can now see it does not fit into that we have to add one what has happened here some fluid is added so volume is increase value volume is increased without increasing osmolality right I'll make one more and if I say it is like this volume is removed out of the body along with the solute because this molality did not change right so this is volume as this is isotonic volume contraction so it means what what type of volume is last isotonic fluid is lost out of the body in which situation isotonic fluid goes out diarrhea Hemorrhage vomiting Hammer clear no problem up to this just enough for Today class distance