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'{{Technical|date=June 2009}} {{Infobox medical condition (new) | name = Hypovolemia | synonyms = Oligemia, hypovolaemia, oligaemia, hypovolæmia, volume depletion | image = | caption = | field = [[Emergency medicine]] | symptoms = headache, fatigue, nausea, profuse sweating, dizziness | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = |alt=}} '''Hypovolemia''', also known as '''volume depletion''' or '''volume contraction''', is a state of decreased intravascular volume.<ref name="McGee 2018 p. ">{{cite book | last=McGee | first=Steven | name-list-format = vanc | title=Evidence-based physical diagnosis | publisher=Elsevier | location=Philadelphia, PA | year=2018 | isbn=978-0-323-39276-1 | oclc=959371826 | page= | quote=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.}}</ref> This may be due to either a loss of both salt and water or a decrease in blood volume.<ref>{{cite web|url=http://www.medterms.com/script/main/art.asp?articlekey=3871 |title=Hypovolemia definition - MedicineNet - Health and Medical Information Produced by Doctors |publisher=Medterms.com |date=2012-03-19 |access-date=2015-11-01}}</ref><ref>{{cite web|url=http://medical-dictionary.thefreedictionary.com/hypovolemia |title=Hypovolemia &#124; definition of hypovolemia by Medical dictionary |publisher=Medical-dictionary.thefreedictionary.com |date= |access-date=2015-11-01}}</ref> Hypovolemia refers to the loss of extracellular fluid and should not be confused with [[dehydration]].<ref>{{cite journal | vauthors = Bhave G, Neilson EG | title = Volume depletion versus dehydration: how understanding the difference can guide therapy | journal = American Journal of Kidney Diseases | volume = 58 | issue = 2 | pages = 302–9 | date = August 2011 | pmid = 21705120 | pmc = 4096820 | doi = 10.1053/j.ajkd.2011.02.395 }}</ref> Dehydration refers to excessive total body water loss that results in cellular [[hypertonicity]] (a relatively substantial loss of fluid within individual cells). 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.<ref name=":0">{{Cite book|title=Harrison's principles of internal medicine|editor-last1=Jameson|editor-first1=J. Larry|editor-last2=Kasper|editor-first2=Dennis L.|editor-last3=Longo|editor-first3=Dan L.|editor-last4=Fauci|editor-first4=Anthony S.|editor-last5=Hauser|editor-first5=Stephen L.|editor-last6=Loscalzo|editor-first6=Joseph|isbn=9781259644030|edition=20th|location=New York|publisher=[[McGraw-Hill Education]]|oclc=1029074059|date=2018-08-13}}</ref> The signs and symptoms of hypovolemia worsen as the amount of fluid lost increases.<ref>{{Cite web|url=https://medlineplus.gov/ency/article/000167.htm|title=Hypovolemic shock: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2019-09-02}}</ref> 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 hypovolemic shock<ref>{{Cite journal|last=Kolecki|first=Paul| name-list-format = vanc |date=October 13, 2016|title=Hypovolemic Shock|url=https://emedicine.medscape.com/article/760145-overview|journal=Medscape|volume=|pages=|via=}}</ref>. 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. ==Signs and symptoms== Signs and symptoms of hypovolemia progress with increased loss of fluid volume.<ref name=":0" /> Early symptoms of hypovolemia include headache, fatigue, weakness, thirst, and dizziness. ssssssssssssssssssssssstuff 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:<ref name=":0" /> ===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 [[Mineralocorticoid|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]]<ref>{{cite journal | vauthors = Danic B, Gouézec H, Bigant E, Thomas T | title = [Incidents of blood donation] | language = French | journal = Transfusion Clinique et Biologique | volume = 12 | issue = 2 | pages = 153–9 | date = June 2005 | pmid = 15894504 | doi = 10.1016/j.tracli.2005.04.003 }}</ref>) == Pathophysiology == [[Image:170225 CVS Hypovolemic Shock Pathophysiology of Disease.png|thumb|upright1.3|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.<ref>{{Citation|last=Taghavi|first=Sharven|title=Hypovolemic Shock|date=2019|url=http://www.ncbi.nlm.nih.gov/books/NBK513297/|work=StatPearls|publisher=StatPearls Publishing|pmid=30020669|access-date=2019-09-02|last2=Askari|first2=Reza | name-list-format = vanc }}</ref> In order to properly perform their functions, tissues require the oxygen transported in the blood.<ref>{{cite journal | vauthors = Carreau A, El Hafny-Rahbi B, Matejuk A, Grillon C, Kieda C | title = Why is the partial oxygen pressure of human tissues a crucial parameter? Small molecules and hypoxia | journal = Journal of Cellular and Molecular Medicine | volume = 15 | issue = 6 | pages = 1239–53 | date = June 2011 | pmid = 21251211 | pmc = 4373326 | doi = 10.1111/j.1582-4934.2011.01258.x }}</ref> A decrease in circulating volume can lead to a decrease in blood perfusion to the brain, resulting in headache and dizziness. Altered mental status progresses as hypovolemia continues. Baroreceptors in the body (primarily those located in the [[Carotid sinus|carotid sinuses]] and [[aortic arch]]) sense the reduction of circulating fluid and send signals to the brain to increase sympathetic response (''see also: [[baroreflex]]'').<ref>{{cite book | vauthors = Armstrong M, Moore RA | chapter = Physiology, Baroreceptors | date = 2019 | pmid = 30844199 | chapter-url = http://www.ncbi.nlm.nih.gov/books/NBK538172/ | access-date = 2019-09-02 | publisher = StatPearls Publishing | title = StatPearls }}</ref> This sympathetic response is to release [[Adrenaline|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. ==Diagnosis== {{see also|Shock index}} Hypovolemia can be recognized by a [[fast heart rate]], [[low blood pressure]],<ref>{{cite web|url=http://www.stagesofshock.com/stage3/index.html |title=Stage 3: Compensated Shock|archive-url=https://web.archive.org/web/20100611035541/http://www.stagesofshock.com/stage3/index.html |archive-date=2010-06-11}}</ref> and the absence of [[perfusion]] as assessed by skin signs (skin turning pale) and/or [[capillary refill]] on [[forehead]], [[lip]]s and [[nail beds]]. The patient may feel dizzy, faint, nauseated, or very thirsty. These signs are also characteristic of most types of [[Shock (circulatory)|shock]].<ref name="Alpert Ewy">{{cite book| first1 = Joseph S. | last1 = Alpert | first2 = Gordon A. | last2 = Ewy | name-list-format = vanc |title=Manual of Cardiovascular Diagnosis and Therapy|url=https://books.google.com/books?id=Qr9umARYOBYC&pg=PA101|year=2002|publisher=Lippincott Williams & Wilkins|isbn=978-0-7817-2803-4|page=101}}</ref> 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 ([[Decompensation|decompensate]]).<ref name="Stapleton">{{cite book| first1 = Mark C | last1 = Henry | first2 = Edward R | last2 = Stapleton | first3 = Dennis | last3 = Edgerly | name-list-format = vanc |title=EMT Prehospital Care |url= https://books.google.com/books?id=LPoXkd4yN1AC&pg=PA471 |date=26 July 2011|publisher=Jones & Bartlett Publishers|isbn=978-0-323-08533-5|pages=471–}}</ref> Consequently, any possibility of [[internal bleeding]] in children should be treated aggressively.<ref name="Beevi">{{cite book|author=Assuma Beevi|title=Pediatric Nursing Care Plans|url=https://books.google.com/books?id=2pQGoymRB9YC&pg=PT47|date=31 August 2012|publisher=JP Medical Ltd|isbn=978-93-5025-868-2|pages=47–}}</ref><ref name="Clement" /> Signs of external bleeding should be assessed, noting that individuals can bleed internally without external blood loss or otherwise apparent signs.<ref name="Clement">{{cite book| vauthors = Clement I |title=Textbook on First Aid and Emergency Nursing|url=https://books.google.com/books?id=AC__AwAAQBAJ&pg=PA113|date=20 May 2013|publisher=Jaypee Brothers Publishers|isbn=978-93-5025-987-0|pages=113–}}</ref> 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 [[Advanced Trauma Life Support#Secondary survey|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).<ref name="Amanda Graham">{{cite book| last1 = Blaber | first1 = Amanda | last2 = Harris | first2 = Graham | name-list-format = vanc |title=Assessment Skills For Paramedics|url=https://books.google.com/books?id=jfPbQbvP1yAC&pg=PA83|date=1 October 2011|publisher=McGraw-Hill Education|isbn=978-0-335-24199-6|pages=83–}}</ref> ===Investigation=== In a hospital, physicians respond to a case of hypovolemic shock by conducting these investigations: * Blood tests: [[Basic metabolic panel|U+Es/Chem7]], full blood count, glucose, blood type and screen *[[Central venous catheter]] *[[Arterial line]] * Urine output measurements (via [[urinary catheterization|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;<ref name="dynamicnursingeducation.com">{{cite web|author=Hudson, Kristi|url=http://dynamicnursingeducation.com/class.php?class_id=47&pid=18|title=Hypovolemic Shock - 1 Nursing CE|archive-url=https://web.archive.org/web/20090606044910/http://dynamicnursingeducation.com/class.php?class_id=47&pid=18 |archive-date=2009-06-06}}</ref> however, a number of other systems exist with as many as 6 stages.<ref>{{cite web|url=http://www.stagesofshock.com/stage1/index.html|title=Stage 1: Anticipation stage (a new paradigm)|archive-url=https://web.archive.org/web/20100116055045/http://www.stagesofshock.com/stage1/index.html|archive-date=2010-01-16}}</ref> 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.<ref name=emergencycare>{{cite book|editor1-last=Greaves|editor1-first=Ian|editor2-last=Porter|editor2-first=Keith|editor3-last=Hodgetts|editor3-first=Timothy|display-editors = 3 |editor4-last=Woollard|editor4-first=Malcolm| name-list-format = vanc |title=Emergency Care: A Textbook for Paramedics|date=2006|publisher=Elsevier Health Sciences|isbn=9780702025860|page=229}}</ref> 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:<ref name=agabegi2nd>{{cite book | first1 = Elizabeth D | last1 = Agabegi | first2 = Agabegi | last2 = Steven S. | name-list-format = vanc | title = Step-Up to Medicine (Step-Up Series) | publisher = Lippincott Williams & Wilkins | location = Hagerstwon, MD | year = 2008 | pages = | isbn = 978-0-7817-7153-5 | oclc = | doi = | access-date = | url-access = registration | url = https://archive.org/details/stepuptomedicine0000agab }}</ref><ref>{{Cite book|title=Robbins and Cotran pathologic basis of disease|editor-last1=Kumar|editor-first1=Vinay|editor-last2=Abbas|editor-first2=Abul K.|editor-last3=Aster|editor-first3=Jon C.|others=Illustrated by Perkins, James A.|date=2015|isbn=9781455726134|edition=9th|location=Philadelphia, PA|publisher=[[Saunders]]|oclc=879416939}}</ref> {| class="wikitable" style="margin: 1em auto 1em auto;" ! scope="col" | ! scope="col" | '''Stage 1''' ! scope="col" | '''Stage 2''' ! scope="col" | '''Stage 3''' ! scope="col" | '''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<br/>by [[vasoconstriction]]) || Increased [[diastolic blood pressure|diastolic BP]] || [[Systolic blood pressure|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) || [[Tachypnea|Tachypneic]] (> 30) || Extreme [[tachypnea]] |- | '''Mental status''' || Normal || Slight anxiety, restless || [[Altered mental status|Altered]], confused || Decreased [[level of consciousness|LOC]], [[lethargy]], [[coma]] |- | '''Skin''' || [[Pallor|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.<ref>{{cite journal |last=Bulger |first=E. M. |last2=Snyder |first2=D. |last3=Schoelles |first3=K. |last4=Gotschall |first4=C. |last5=Dawson |first5=D. |last6=Lang |first6=E. |last7=White |first7=L. |displayauthors=1 |year=2014 |title=An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma |journal=Prehospital Emergency Care |volume=18 |issue=2 |pages=163–173 |doi=10.3109/10903127.2014.896962 |pmid=24641269 }}</ref> Medical personnel should immediately supply emergency oxygen to increase efficiency of the patient's remaining blood supply. This intervention can be life-saving.<ref>{{cite journal |last=Takasu |first=A. |last2=Prueckner |first2=S. |last3=Tisherman |first3=S. A. |last4=Stezoski |first4=S. W. |last5=Stezoski |first5=J. |last6=Safar |first6=P. |year=2000 |title=Effects of increased oxygen breathing in a volume controlled hemorrhagic shock outcome model in rats |journal=Resuscitation |volume=45 |issue=3 |pages=209–220 |pmid=10959021 |doi=10.1016/s0300-9572(00)00183-0 }}</ref> The use of [[intravenous drip|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 fluids|colloid]] or [[crystalloid fluid|crystalloid]] IV fluids also dilutes [[clotting factor]]s in the blood, increasing the risk of bleeding. Current best practice allow [[permissive hypotension]] in patients suffering from hypovolemic shock,<ref>{{cite web |url=http://www.trauma.org/archive/resus/permissivehypotension.html |title=Permissive Hypotension |publisher=Trauma.Org |date=1997-08-31 |access-date=2015-11-01 |archive-url=https://web.archive.org/web/20131127011402/http://www.trauma.org/archive/resus/permissivehypotension.html |archive-date=2013-11-27 |url-status=dead }}</ref> both avoid overly diluting clotting factors and avoid artificially raising blood pressure to a point where it "blows off" clots that have formed.<ref name="AAOS">{{cite book | first = Mike | last = Kennamer | author2 = American Academy of Orthopaedic Surgeons (AAOS) | name-list-format = vanc |title=Intravenous Therapy for Prehospital Providers|url=https://books.google.com/books?id=YB2VAgAAQBAJ&pg=PA63|date=30 September 2013|publisher=Jones & Bartlett Publishers|isbn=978-1-4496-4204-4|pages=63–}}</ref><ref name="Franchis Dell'Era">{{cite book| first1 = Roberto | last1 = de Franchis | first2 = Alessandra | last2 = Dell'Era | name-list-format = vanc |title=Variceal Hemorrhage|url=https://books.google.com/books?id=YrW9BAAAQBAJ&pg=PA113|date=25 January 2014|publisher=Springer Science & Business Media|isbn=978-1-4939-0002-2|pages=113–}}</ref> ===Hospital treatment=== [[Fluid replacement]] is beneficial in hypovolemia of stage 2, and is necessary in stage 3 and 4.<ref name=agabegi2nd /> See also the discussion of [[Shock (circulatory)|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 (medicine)|dopamine]] and [[Norepinephrine (drug)|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.<ref>{{cite journal|url=https://www.ncbi.nlm.nih.gov/pubmed?term=9001880 |title=Failure of dobutamine to improve liver oxygenation during resuscitation with a crystalloid solution after experimental haemorrhagic shock|journal=The European Journal of Surgery = Acta Chirurgica|volume=162|issue=12|pages=973–979|publisher=Pubmed-NCBI |date=1996-08-31 |access-date=2017-11-21|last1=Nordin|first1=A. J.|last2=Mäkisalo|first2=H.|last3=Höckerstedt|first3=K. A.}}</ref> ==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.<ref>{{cite journal | vauthors = Geeraedts LM, Kaasjager HA, van Vugt AB, Frölke JP | title = Exsanguination in trauma: A review of diagnostics and treatment options | journal = Injury | volume = 40 | issue = 1 | pages = 11–20 | date = January 2009 | pmid = 19135193 | doi = 10.1016/j.injury.2008.10.007 }}</ref> == 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 == {{Reflist|colwidth=30em}} == External links == {{Medical resources | DiseasesDB = 29217 | ICD10 = {{ICD10|E|86||e|70}}, {{ICD10|R|57|1|r|50}}, {{ICD10|T|81|1|t|80}} | ICD9 = {{ICD9|276.52}} | ICDO = | OMIM = | MedlinePlus = 000167 | eMedicineSubj = | eMedicineTopic = | MeshID = D020896 }} {{shock types}} {{Water-electrolyte imbalance and acid-base imbalance}} {{Cardiovascular system symptoms and signs}} [[Category:Blood disorders]] [[Category:Medical emergencies]]'