History and exam
Key diagnostic factors
common
postural dizziness
When hemorrhage is suspected, it has a sensitivity of 22% for moderate blood loss and 97% for severe blood loss. The specificity is 98%. This finding is less well established with volume depletion from other causes.[2] It can also be a sign of autonomic insufficiency, which is not volume depletion.
weight loss
A decrease from baseline weight.
orthostatic hypotension
A >20 mmHg decrease in systolic blood pressure from supine to standing has a sensitivity of 9% for moderate blood loss in those <65 years old and 27% for those >65 years old.[2] A drop in diastolic pressure of >10 mmHg from supine to standing is also considered supportive of volume depletion. Orthostatic hypotension may also exist in cases of autonomic insufficiency or from treatment with certain antihypertensive medications. It may be best to avoid checking orthostatic changes in patients with systolic blood pressure <90 mmHg.
postural tachycardia
An increase in pulse rate of >30 beats/minute from supine to standing has a sensitivity of 22% for moderate blood loss and 97% for severe blood loss. The specificity is 98%. This finding is less well established with volume depletion from other causes.[2]
signs of shock
End result of severe volume depletion resulting in poor tissue perfusion and ischemia.
Other diagnostic factors
common
decreased urine output
Patient may note decreased urinary frequency or volume, or more concentrated urine.
diarrhea
Patients with frequent and severe diarrhea may be unable to maintain adequate oral intake to compensate for these losses and so become volume-depleted. The elderly and children are especially vulnerable.
vomiting
Patients with frequent and severe vomiting are often unable to maintain adequate oral intake to compensate for these losses and so become volume-depleted. The elderly and children are especially vulnerable.
melena
The passage of characteristic black, tarry, foul-smelling stool is indicative of blood from a gastric or duodenal hemorrhage that has passed through the ileum and colon. Such bleeds are a frequent cause of volume depletion.
hematochezia
The passage of significant amounts of bright red bloody stool is an important indicator for the possibility of volume depletion.
high-volume gastrointestinal drainage
Hospitalized patients may become volume-depleted due to large volume losses from nasogastric suction or enteral drainage if they do not receive appropriate maintenance or replacement fluids.
polyuria
May be associated with uncontrolled diabetes and the presence of glucose in the urine causing osmotic diuresis.
poor oral intake
A sustained poor intake of fluids and solutes can result in volume depletion. Children and the elderly are especially vulnerable.
severe sweating
Prolonged heavy physical exertion in warm environments, with limited access to solute and water replacement, can quickly lead to volume depletion.
burns
Likelihood depends on the size of the burn. If extensive, burns can quickly lead to volume depletion as the fluid lost has a similar solute composition to plasma.
intestinal obstruction
As much as 7-8 L of fluid can be sequestered in the bowel, especially when the obstruction is distal.
severe pancreatitis
Substantial volumes may be sequestered in the retroperitoneum.
crush injuries
This can lead to blood and fluid being sequestered into a third space, such as the thigh muscle compartment.
intra-abdominal bleeding
Substantial volumes may be lost into the abdominal cavity.
fatigue
Nonspecific; may be a manifestation of decreased tissue perfusion.
thirst
Nonspecific; may be seen with volume depletion alone, but is greatest in settings of true water depletion (dehydration and hypernatremia), with or without hypovolemia. Volume depletion can stimulate thirst, but an increase in serum osmolality, as seen in dehydration, is the strongest stimulus of thirst.
dry mucous membranes
Suggests volume depletion, and is more helpful in the setting of vomiting or diarrhea. It is not very useful for blood loss.
uncommon
muscle cramps
May be a reflection of decreased tissue perfusion or electrolyte abnormalities.
abdominal pain
In patients with significant atherosclerosis of the mesenteric vasculature, abdominal ischemia due to severe volume loss can result in abdominal pain. However, it can also be a symptom of intra-abdominal bleeding, bowel obstruction, or pancreatitis.
chest pain
Volume depletion in patients with coronary atherosclerosis can result in cardiac ischemia and angina due to hypotension.
confusion
Nonspecific; but may reflect poor cerebral blood flow or uremia in the setting of impaired kidney function.
decreased skin turgor
Can suggest decreased interstitial fluid volume, especially in younger adults. This sign is less helpful in older adults as they have decreased elasticity of their skin as part of aging.
Risk factors
strong
diuretic therapy
Volume depletion often manifests after an increase in diuretic therapy or during an acute illness in a patient on diuretics. In patients with heart failure, in particular, there is a delicate balance between euvolemia, and hyper- and hypovolemia, and even small changes in diuretic dose or fluid intake can upset this balance.
chronic kidney disease
With chronic renal vasoconstriction, a small drop in effective circulating volume can have large clinical effects.
older adult
These patients may have motivational or practical difficulties preparing food and drink for themselves. They can easily become volume-depleted if appropriate amounts of water and solutes are not made readily available or without assistance given to enable them to take in sufficient volumes.
altered mental status
Patients with a reduced level of consciousness who are unable to drink and regulate their own intake of water and solutes can become volume-depleted unless appropriate fluids are administered by nasogastric or intravenous routes.
weak
high ambient temperature
Prolonged heavy physical exertion in warm environments, with limited access to solute and water replacement, can quickly lead to volume depletion through excessive sweating.
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