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Hypovolemia
Other names Oligemia, hypovolaemia, oligaemia, hypovolæmia, volume depletion
Specialty Emergency medicine
Symptoms headache, fatigue, nausea, profuse sweating, dizziness
Hypovolemia, also known as volume depletion or volume contraction, is a state of
abnormally low extracellular fluid in the body.[1] This may be due to either a loss
of both salt and water or a decrease in blood volume.[2][3] Hypovolemia refers to
the loss of extracellular fluid and should not be confused with dehydration.[4]

Hypovolemia is caused by a variety of events, but these can be simplified into two
categories: those that are associated with kidney function and those that are not.
[5] The signs and symptoms of hypovolemia worsen as the amount of fluid lost
increases.[6] Immediately or shortly after mild fluid loss, one may experience
headache, fatigue, weakness, dizziness or thirst (as in blood transfusion,
diarrhea, vomiting). Untreated hypovolemia or excessive and rapid losses of volume
may lead to hypovolemic shock.[7] Signs and symptoms of hypovolemic shock include
increased heart rate, low blood pressure, pale or cold skin, and altered mental
status. When these signs are seen, immediate action should be taken to restore the
lost volume.

Contents
1 Signs and symptoms
2 Causes
2.1 Kidney
2.2 Other
3 Pathophysiology
4 Diagnosis
4.1 Investigation
4.2 Stages
5 Treatment
5.1 Field care
5.2 Hospital treatment
6 History
7 See also
8 References
9 External links
Signs and symptoms
Signs and symptoms of hypovolemia progress with increased loss of fluid volume.[5]

Early symptoms of hypovolemia include headache, fatigue, weakness, thirst, and

dizziness.

The more severe signs and symptoms are often associated with hypovolemic shock.
These include oliguria, cyanosis, abdominal and chest pain, hypotension,
tachycardia, cold hands and feet, and progressively altering mental status.

Causes
The causes of hypovolemia can be characterized into two categories:[5]

Kidney
Loss of body sodium and consequent intravascular water (due to impaired
reabsorption of salt and water in the tubules of the kidneys)
Osmotic diuresis: the increase in urine production due to an excess of osmotic
(namely glucose and urea) load in the tubules of the kidneys
Overuse of pharmacologic diuretics
Impaired response to hormones controlling salt and water balance (see
mineralocorticoids)
Impaired kidney function due to tubular injury or other diseases
Other
Loss of bodily fluids due to:
Gastrointestinal losses; e.g. vomiting and diarrhea
Skin losses; e.g. excessive sweating and burns
Respiratory losses; e.g. hyperventilation (breathing fast)
Build up of fluid in empty spaces (third spaces) of the body due to:
Acute pancreatitis
Intestinal obstruction
Increase in vascular permeability
Hypoalbuminemia
Loss of blood (external or internal bleeding or blood donation[8])
Pathophysiology

Pathophysiology of hypovolemia
The signs and symptoms of hypovolemia are primarily due to the consequences of
decreased circulating volume and a subsequent reduction in the amount of blood
reaching the tissues of the body.[9] In order to properly perform their functions,
tissues require the oxygen transported in the blood.[10] A decrease in circulating
volume can lead to a decrease in bloodflow to the brain, resulting in headache and
dizziness.

Baroreceptors in the body (primarily those located in the carotid sinuses and
aortic arch) sense the reduction of circulating fluid and send signals to the brain
to increase sympathetic response (see also: baroreflex).[11] This sympathetic
response is to release epinephrine and norepinephrine, which results in peripheral
vasoconstriction (reducing size of blood vessels) in order to conserve the
circulating fluids for organs vital to survival (i.e. brain and heart). Peripheral
vasoconstriction accounts for the cold extremities (hands and feet), increased
heart rate, increased cardiac output (and associated chest pain). Eventually, there
will be less perfusion to the kidneys, resulting in decreased urine output.
[citation needed]

Diagnosis
See also: Shock index
Hypovolemia can be recognized by a fast heart rate, low blood pressure,[12] and the
absence of perfusion as assessed by skin signs (skin turning pale) and/or capillary
refill on forehead, lips and nail beds. The patient may feel dizzy, faint,
nauseated, or very thirsty. These signs are also characteristic of most types of
shock.[13]

In children, compensation can result in an artificially high blood pressure despite

hypovolemia (a decrease in blood volume). Children typically are able to compensate
(maintain blood pressure despite hypovolemia) for a longer period than adults, but
deteriorate rapidly and severely once they are unable to compensate (decompensate).
[14] Consequently, any possibility of internal bleeding in children should be
treated aggressively.[15][16]

Signs of external bleeding should be assessed, noting that individuals can bleed
internally without external blood loss or otherwise apparent signs.[16]

There should be considered possible mechanisms of injury that may have caused
internal bleeding, such as ruptured or bruised internal organs. If trained to do so
and if the situation permits, there should be conducted a secondary survey and
checked the chest and abdomen for pain, deformity, guarding, discoloration or
swelling. Bleeding into the abdominal cavity can cause the classical bruising
patterns of Grey Turner's sign (bruising along the sides) or Cullen's sign (around
the navel).[17]

Investigation
In a hospital, physicians respond to a case of hypovolemic shock by conducting
these investigations:

Blood tests: U+Es/Chem7, full blood count, glucose, blood type and screen
Central venous catheter
Arterial line
Urine output measurements (via urinary catheter)
Blood pressure
SpO2 oxygen saturation monitoring
Stages
Untreated hypovolemia can lead to shock (see also: hypovolemic shock). Most sources
state that there are 4 stages of hypovolemia and subsequent shock;[18] however, a
number of other systems exist with as many as 6 stages.[19]

The 4 stages are sometimes known as the "Tennis" staging of hypovolemic shock, as
the stages of blood loss (under 15% of volume, 15–30% of volume, 30–40% of volume
and above 40% of volume) mimic the scores in a game of tennis: 15, 15–30, 30–40 and
40.[20] It is basically the same as used in classifying bleeding by blood loss.

The signs and symptoms of the major stages of hypovolemic shock include:[21][22]

Stage 1 Stage 2 Stage 3 Stage 4

Blood loss Up to 15% (750 mL) 15–30% (750–1500 mL) 30–40% (1500–2000 mL)
Over 40% (over 2000 mL)
Blood pressure Normal (Maintained
by vasoconstriction) Increased diastolic BP Systolic BP < 100 Systolic BP < 70
Heart rate Normal Slight tachycardia (> 100 bpm) Tachycardia (> 120 bpm)
Extreme tachycardia (> 140 bpm) with weak pulse
Respiratory rate Normal Increased (> 20) Tachypneic (> 30) Extreme tachypnea
Mental status Normal Slight anxiety, restless Altered, confused
Decreased LOC, lethargy, coma
Skin Pale Pale, cool, clammy Increased diaphoresis Extreme diaphoresis;
mottling possible
Capillary refill Normal Delayed Delayed Absent
Urine output Normal 20–30 mL/h 20 mL/h Negligible
Treatment
Field care
The most important step in treatment of hypovolemic shock is to identify and
control the source of bleeding.[23]

Medical personnel should immediately supply emergency oxygen to increase efficiency

of the patient's remaining blood supply. This intervention can be life-saving.[24]

The use of intravenous fluids (IVs) may help compensate for lost fluid volume, but
IV fluids cannot carry oxygen the way blood does—however, researchers are
developing blood substitutes that can. Infusing colloid or crystalloid IV fluids
also dilutes clotting factors in the blood, increasing the risk of bleeding.
Current best practice allow permissive hypotension in patients suffering from
hypovolemic shock,[25] both avoid overly diluting clotting factors and avoid
artificially raising blood pressure to a point where it "blows off" clots that have
formed.[26][27]

Hospital treatment
Fluid replacement is beneficial in hypovolemia of stage 2, and is necessary in
stage 3 and 4.[21] See also the discussion of shock and the importance of treating
reversible shock while it can still be countered.

The following interventions are carried out:

IV access
Oxygen as required
Fresh frozen plasma or blood transfusion
Surgical repair at sites of bleeding
Vasopressors (such as dopamine and noradrenaline) should generally be avoided, as
they may result in further tissue ischemia and don't correct the primary problem.
Fluids are the preferred choice of therapy.[28]

History
In cases where loss of blood volume is clearly attributable to bleeding (as opposed
to, e.g., dehydration), most medical practitioners prefer the term exsanguination
for its greater specificity and descriptiveness, with the effect that the latter
term is now more common in the relevant context.[29]

See also
Hypervolemia
Non-pneumatic anti-shock garment
Polycythemia, an increase of the hematocrit level, with the "relative polycythemia"
being a decrease in the volume of plasma
Volume status
References
McGee S (2018). Evidence-based physical diagnosis. Philadelphia, PA: Elsevier.
ISBN 978-0-323-39276-1. OCLC 959371826. The term hypovolemia refers collectively to
two distinct disorders: (1) volume depletion, which describes the loss of sodium
from the extracellular space (i.e., intravascular and interstitial fluid) that
occurs during gastrointestinal hemorrhage, vomiting, diarrhea, and diuresis; and
(2) dehydration, which refers to the loss of intracellular water (and total body
water) that ultimately causes cellular desiccation and elevates the plasma sodium
concentration and osmolality.
"Hypovolemia definition - MedicineNet - Health and Medical Information Produced by
Doctors". Medterms.com. 2012-03-19. Retrieved 2015-11-01.
"Hypovolemia | definition of hypovolemia by Medical dictionary". Medical-
dictionary.thefreedictionary.com. Retrieved 2015-11-01.
Bhave G, Neilson EG (August 2011). "Volume depletion versus dehydration: how
understanding the difference can guide therapy". American Journal of Kidney
Diseases. 58 (2): 302–9. doi:10.1053/j.ajkd.2011.02.395. PMC 4096820. PMID
21705120.
Jameson, J. Larry; Kasper, Dennis L.; Longo, Dan L.; Fauci, Anthony S.; Hauser,
Stephen L.; Loscalzo, Joseph, eds. (2018-08-13). Harrison's principles of internal
medicine (20th ed.). New York: McGraw-Hill Education. ISBN 9781259644030. OCLC
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"Hypovolemic shock: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved
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Kolecki P (October 13, 2016). "Hypovolemic Shock". Medscape.
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doi:10.1016/j.tracli.2005.04.003. PMID 15894504.
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External links
Classification D
ICD-10: E86, R57.1, T81.1ICD-9-CM: 276.52MeSH: D020896DiseasesDB: 29217
External resources
MedlinePlus: 000167
vte
Shock
vte
Acid–base disorders
vte
Symptoms and signs relating to the cardiovascular system
Categories: Blood disordersMedical emergencies
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