HYPOVOLEMIA

A. Causes
Volume depletion generally results from a deficit in total body
Na+ content. This may result from renal or extrarenal losses
of Na + from the ECF. Water losses alone can also cause volume
depletion, but the quantity required to do so is large, as water is
lost mainly from the ICF and not the ECF, where volume
contraction can be assessed.
Renal losses may be secondary to enhanced diuresis, saltwasting nephropathies, mineralocorticoid deficiency, or the
resolution of obstructive renal disease.
Extrarenal losses include fluid loss from the GI tract
(vomiting, nasogastric suction, fistula drainage, diarrhea),
respiratory losses, skin losses (especially with burns),
hemorrhage, and severe third spacing of fluid in critical illness.
1. GI losses due to vomiting, nasogastric suction, diarrhea,
fistula drainage, etc.
2. Third-spacing due to ascites, effusions, bowel obstruction,
crush injuries, burns.
3. Inadequate intake
4. Polyuria for example, DKA.
5. Sepsis, intra-abdominal and retroperitoneal inflammatory
processes.
6. Trauma, open wounds, sequestration of fluid into soft tissue
injuries.
7. Insensible losses evaporatory losses through the skin (75%)
and the respiratory tract (25%)
B. Clinical features
SYMPTOMS: include complaints of thirst, fatigue, weakness,
muscle cramps, and postural dizziness. Sometimes, syncope and
coma can result with severe volume depletion.
SIGNS: low jugular venous pressure, postural hypotension,
postural tachycardia, and the absence of axillary sweat.
Diminished skin turgor and dry mucous membranes are poor
markers of decreased interstitial fluid. Mild degrees of volume
depletion are often not clinically detectable, while larger fluid

losses can lead to mental status changes, oliguria, and

hypovolemic shock.
1. CNS findings: mental status changes, sleepiness, apathy,
coma.
2. Cardiovascular findings (due to decrease in plasma volume):
orthostatic hypotension, tachycardia, decreased pulse
pressure, decreased central venous pressure (CVP), and
pulmonary capillary wedge pressure (PCWP).
3. Skin: poor skin turgor, hypothermia, pale extremities, dry
tongue.
4. Oliguria
5. Ileus, weakness
6. Acute renal failure due to prerenal azotemia (fractional
excretion of sodium <1% and/or BUN/Cr >20.)
C. Diagnosis
Laboratory studies are often helpful but must be used in
conjunction with the clinical picture.

Urine Sodium is a marker for Na+ avidity in the kidney.

-Urine Na+ < 15mEq is consistent with volume depletion,
as is a fractional excretion of sodium (FeNa) < 1%. The
latter can be calculated as [(Urine Na+ x Serum Cr)/(Urine
Cr x Serum Na+)] x 100
-Concomitant metabolic alkalosis may increase urine Na+
excretion despite volume depletion due to obligate
excretion of Na+ to accompany the bicarbonate anion. In
such cases, a urine Chloride of <20mEq is often helpful to
confirm volume contraction.

Urine osmolality and serum bicarbonate levels may

also be elevated.

Hematocrit and serum albumin may be increased from

hemoconcentration.

1. Monitor urine output and daily weights. If the patient is

critically ill and has cardiac or renal dysfunction, consider
placing a Swan-Ganz catheter (to measure CVP or PCWP).

2. Elevated serum sodium, low urine sodium, low urine sodium,

and a BUN/Cr ratio of >20:1 suggest hypoperfusion to the
kidneys, which usually (not always) represents hypovolemia.
3. Increased hematocrit: 3% increase for each liter of deficit.
4. The concentration of formed elements in the flood (RBC,
WBCs, platelets, plasma proteins) increases with an ECF
deficits and decreases with an ECF excess.
D. Treatment

It is often difficult to estimate to volume deficit present, and

therapy is thus largely empiric, requiring frequent reassessments
of volume status while resuscitation is under way.

Mild volume contraction can usually be corrected via the oral

route. However, the presence of hemodynamic instability,
symptomatic fluid loss, or intolerance to oral administration
requires IV therapy.

The primary therapeutic goal is to protect hemodynamic stability

and replenish intravascular volume with fluid that will
preferentially expand the ECF compartment. This can be
accomplished with Na+ - based solutions, since the Na+ will be
retained in the ECF.

-Isotonic fluid, such as NS (.9% NaCl), contains a Na+ content

similar to that of plasma fluid in the ECF and thus remains entirely
in the ECF space. It is the initial fluid of choice for replenishing
intravascular volume.
The administration of solute-free water is largely ineffective,
since the majority of water will distribute to the ICF space.
Half-normal saline (.45% NS) has 77 mEq of Na+ per liter, roughly
half the Na+ content of an equal volume in the ECF. Thus, half of
this solution will stay in the ECF, and half will follow the predicted
distribution of water.
-Fluids can be administered as a bolus or at a steady maintenance
rate. In patients with symptomatic volume depletion, a 1 to 2-L
bolus is often preferable to acutely expand the intravascular space.

This should be followed by a careful reassessment of the patients

volume status. The bolus can be repeated if necessary, although
close attention should be directed toward possible signs of volume
overload. Smaller boluses should be used for patient with poor
cardiac reserve or significant edema. Once the patient is stable,
fluids can be administered at a maintenance rate to replace ongoing
losses. In patients with hemorrhage or GI bleeding, blood
transfusion can accomplish both volume expansion and
concomitant correction of anemia.
1. Correct volume deficit
A. Use bolus to achieve euvolemia. Begin with isotonic solution
(lactated Ringers or NS).
B. Again, frequent monitoring of HR, BP, urine output, and
weight is essential.
C. Maintain Urine output at .5 to 1 mL/kg/hour
D. Blood loss replace blood loss with crystalloid at a 3:1 ratio
2. Maintenance fluid
A. D51/ 2NS solution with 20mEq KCL/L is the most common
adult maintenance fluid. (Dextrose is added to inhibit muscle
breakdown).
B. There are two methods of calculating the amount of
maintenance fluid.

100 /50 / 20 Rule:

1. 100ml/kg for first 10kg, 50ml/kg for next 10kg, 20ml/kg every 1 kg
over 20.
2. Divide total by 24 for hourly rate
Example: 70kg man
100 X 10 = 1000
50 X 10 = 500
20 X 50 =1000
Total
= 2500
Divide by 24 hrs 104 ml/hr

4 / 2 / 1 Rule:
4ml/kg for first 10kg, 2ml/kg for next 10kg, 1ml/kg for every 1kg over
20.
For example, for a 70kg man:
4 x 10 = 40
2 x 10 = 20

1 x 50 = 50
Total = 110 ml/hr