hypovolemia (extracellular volume depletion)
Jump to navigation
Jump to search
Etiology
- acute hemorrhage
- skin
- diaphoresis
- burns
- dermatitis (weeping)
- interstitial fluid shifts (3rd space)
- crush injury
- pancreatitis
- peritonitis
- bowel obstruction
- bowel necrosis
- rhabdomyolysis
- non cardiac pulmonary edema
- gastrointestinal
- renal
- increased vascular capacity
Indications
Clinical manifestations
- mild volume depletion (< 5%, 1-2 liters)
- thirst
- fatigue
- dry mucosa, dry mouth
- concentrated urine
- capillary refill time may be increased
- moderate volume depletion (5-10%, 2-4 liters)
- anorexia
- nausea
- cramps
- near syncope
- little to no tears & sweat
- tachycardia
- orthostatic hypotension
- decreased urine output
- severe volume depletion (> 10% 4-6 liters)
- moribund (> 20%, 8L)
Laboratory
- urinalysis
- urine sodium
- > 20 meq/L indicates renal Na+ loss, check serum HCO3-
- renal tubular acidosis
- hyperaldosteronism
- check serum K+
- glucose
- mannitol
- < 10 meq/L indicates non renal Na+ loss, check serum HCO3-
- diarrhea
- GI fistula or shunt
- serum HCO3- normal suggests interstitial losses
- intestinal edema
- peritonitis
- pancreatitis
- rhabdomyolysis
- vomiting
- gastric suctioning
- urine chloride
- useful in the context of:
- HCO3- secretion by the proximal tubules into the urine is accompanied by Na+, thus increasing Na+ in the urine
- urine chloride may be used in the same algorithm as urine Na+ for evaluation of extracellular volume depletion
- osmolality > 500 (normal renal function)
- specific gravity increased (normal renal function)
- pH
- urine sodium
- serum
- electrolytes
- glucose
- osmolality
- increased urea nitrogen
- urea nitrogen/creatinine ratio > 20
- increased creatinine with severe volume depletion
- hyperuricemia
- phosphate increased
- protein increased
- fractional excretion of sodium (FENA)
- complete blood count (CBC)
- hemoglobin increased
- hematocrit increased
Management
- large bore peripheral IV for fluid resuscitation[8]
- preferably 2
- restore intravascular volume with normal saline or lactated Ringer's until patient is hemodynamically stable
- 4% albumin may be useful in septic patient (see SAFE study)
- avoid hydroxyethyl starch (Hespan)[3][5][6]
- packed RBC transfusion to replace blood loss
- stop or remove medications that contribute to symptoms
- reassess volume status frequently & adjust accordingly
- mild volume depletion may be replaced orally (Na+ & water)
More general terms
More specific terms
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 682-84
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 267
- ↑ 3.0 3.1 Myburgh JA et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012 Oct 1 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23075127
- ↑ McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination. Is this patient hypovolemic? JAMA. 1999 Mar 17;281(11):1022-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10086438
- ↑ 5.0 5.1 The NNT: Hydroxyethyl Starch for Acute Volume Resuscitation. http://www.thennt.com/nnt/hydroxyethyl-starch-for-acute-volume-resuscitation/
Zarychanski R et al Association of Hydroxyethyl Starch Administration With Mortality and Acute Kidney Injury in Critically Ill Patients Requiring Volume Resuscitation. A Systematic Review and Meta-analysis. JAMA. 2013;309(7):678-688 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23423413 <Internet> http://jama.jamanetwork.com/article.aspx?articleid=1653505 - ↑ 6.0 6.1 FDA MedWatch. June 20, 2013 Hydroxyethyl Starch Solutions: FDA Safety Communication - Boxed Warning on Increased Mortality and Severe Renal Injury and Risk of Bleeding
- ↑ The NNT: Hypovolemia. Diagnostics and Likelihood Ratios, Explained. http://www.thennt.com/lr/hypovolemia/
- ↑ 8.0 8.1 Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015