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Highlights & Basics
- Volume depletion is characterized by a reduction in extracellular fluid volume that occurs when salt and fluid losses exceed intake on a sustained basis.
- The most common etiologies are hemorrhage, vomiting, diarrhea, diuresis, or third-space sequestration.
- A detailed history and physical exam are crucial in determining the etiology.
- Signs and symptoms may include some of the following: postural dizziness, fatigue, confusion, muscle cramps, chest pain, abdominal pain, postural hypotension, or tachycardia.
- Clinical symptoms usually do not manifest until large fluid losses have occurred.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Citations
Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.[Abstract][Full Text]
Cartotto R, Johnson LS, Savetamal A, et al. American burn association clinical practice guidelines on burn shock resuscitation. J Burn Care Res. 2024 May 6;45(3):565-89.[Abstract][Full Text]
1. Mange K, Matsuura D, Cizman B, et al. Language guiding therapy: the case of dehydration versus volume depletion. Ann Intern Med. 1997 Nov 1;127(9):848-53.[Abstract]
2. McGee S, Abernethy WB 3rd, Simel DL. The rational clinical examination: is this patient hypovolemic? JAMA. 1999 Mar 17;281(11):1022-9.[Abstract]
3. Batlle D, Chen S, Haque S. Physiological principles in the clinical evaluation of electrolyte, water, and acid-base disorders. In: Alpern RJ, Caplan MJ, Moe OW, eds. Seldin and Giebisch's the kidney: physiology and pathophysiology. 5th ed. San Diego, CA: Academic Press; 2012:2477-512.
4. Di Somma S, Gori, CS, Grandi T, et al. Fluid assessment and management at the emergency department. Fluid overload diagnosis and management. Contrib Nephrol. 2010;164:227-36.[Abstract]
5. Rose BD, Post TW. Hypovolemic states. In: Clinical physiology of acid-base and electrolyte disorders. 5th ed. New York, NY: McGraw-Hill; 2001:415-46.
6. Lacey J, Corbett J, Forni L, et al. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Ann Med. 2019 May-Jun;51(3-4):232-51.[Abstract][Full Text]
7. Bhave G, Neilson EG. Volume depletion versus dehydration: how understanding the difference can guide therapy. Am J Kidney Dis. 2011 Aug;58(2):302-9.[Abstract][Full Text]
8. Hooper L, Abdelhamid A, Attreed NJ, et al. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev. 2015 Apr 30;2015(4):CD009647.[Abstract][Full Text]
9. Alam NH, Majumder RM, Fuchs GJ. Efficacy and safety of oral rehydration solution with reduced osmolarity in adults with cholera: a randomised double-blind clinical trial. Lancet. 1999 Jul 24;354(9175):296-9.[Abstract]
10. Uribarri J, Oh MS, Carroll HJ. Salt-losing nephropathy: clinical presentation and mechanisms. Am J Nephrol. 1983 Jul-Aug;3(4):193-8.[Abstract]
11. Portilla D, Andreoli TE. Disorders of extracellular volume. In: Johnson RJ, Feehally J, eds. Comprehensive clinical nephrology. London: Mosby International; 2007:77-91.
12. Better OS. Impaired fluid and electrolyte balance in hot climates. Kidney Int Suppl. 1987 Aug;21:S97-101.[Abstract]
13. Standl T, Annecke T, Cascorbi I, et al. The nomenclature, definition and distinction of types of shock. Dtsch Arztebl Int. 2018 Nov 9;115(45):757-68.[Abstract][Full Text]
14. Antman EM. Hemodynamic disturbances. In: Libby P, Bonow R, Mann D, et al, eds. Braunwald's heart disease: a textbook of cardiac medicine. 8th ed. Philadelphia, PA: Saunders; 2008.
15. Powell-Tuck J, Gosling P, Lobo DN, et al. British consensus guidelines on intravenous fluid therapy for adult surgical patients. February 2018 [internet publication].[Full Text]
16. Ostermann M, Awdishu L, Legrand M. Using diuretic therapy in the critically ill patient. Intensive Care Med. 2024 Aug;50(8):1331-4.[Abstract]
17. Wu L, Rodriguez M, El Hachem K, et al. Diuretic treatment in heart Failure: a practical guide for clinicians. J Clin Med. 2024 Jul 30;13(15):4470.[Abstract][Full Text]
18. Brienza N, Giglio MT, Marucci M, et al. Does perioperative hemodynamic optimization protect renal function in surgical patients? A meta-analytic study. Crit Care Med. 2009 Jun;37(6):2079-90.[Abstract]
19. Suri SS, Pamboukian SV. Optimal diuretic strategies in heart failure. Ann Transl Med. 2021 Mar;9(6):517.[Abstract][Full Text]
20. Shaw BH, Garland EM, Black BK, et al. Optimal diagnostic thresholds for diagnosis of orthostatic hypotension with a 'sit-to-stand test'. J Hypertens. 2017 May;35(5):1019-25.[Abstract][Full Text]
21. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011 Apr;21(2):69-72.
22. Fedorowski A, Ricci F, Hamrefors V, et al. Orthostatic hypotension: management of a complex, but common, medical problem. Circ Arrhythm Electrophysiol. 2022 Mar;15(3):e010573.[Abstract][Full Text]
23. Deißler L, Wirth R, Frilling B, et al. Hydration status assessment in older patients. Dtsch Arztebl Int. 2023 Oct 6;120(40):663-9.[Abstract][Full Text]
24. Schwartz JT Jr, Brumback RJ, Lakatos R, et al. Acute compartment syndrome of the thigh. A spectrum of injury. J Bone Joint Surg Am. 1989 Mar;71(3):392-400.[Abstract]
25. Kanlic EM, Pinski SE, Verwiebe EG, et al. Acute morbidity and complications of thigh compartment syndrome: a report of 26 cases. Patient Saf Surg. 2010 Aug 19;4(1):13.[Abstract][Full Text]
26. Uchino S, Bellomo R, Goldsmith D. The meaning of the blood urea nitrogen/creatinine ratio in acute kidney injury. Clin Kidney J. 2012 Apr;5(2):187-91.[Abstract][Full Text]
27. Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021 Nov;47(11):1181-247.[Abstract][Full Text]
28. Trzeciak S, Dellinger RP, Chansky ME, et al. Serum lactate as a predictor of mortality in patients with infection. Intensive Care Med. 2007 Jun;33(6):970-7.[Abstract]
29. Rossaint R, Afshari A, Bouillon B, et al. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care. 2023 Mar 1;27(1):80.[Abstract][Full Text]
30. Caputo N, Fraser R, Paliga A, et al. Triage vital signs do not correlate with serum lactate or base deficit, and are less predictive of operative intervention in penetrating trauma patients: a prospective cohort study. Emerg Med J. 2013 Jul;30(7):546-50.[Abstract]
31. Schuetz P, Birkhahn R, Sherwin R, et al. Serial procalcitonin predicts mortality in severe sepsis patients: results from the multicenter procalcitonin MOnitoring SEpsis (MOSES) Study. Crit Care Med. 2017 May;45(5):781-89.[Abstract][Full Text]
32. Kip MM, Kusters R, IJzerman MJ, et al. A PCT algorithm for discontinuation of antibiotic therapy is a cost-effective way to reduce antibiotic exposure in adult intensive care patients with sepsis. J Med Econ. 2015;18(11):944-53.[Abstract][Full Text]
33. El-Khoury JM, Hoenig MP, Jones GRD, et al. AACC guidance document on laboratory investigation of acute kidney injury. J Appl Lab Med. 2021 Sep 1;6(5):1316-37.[Abstract][Full Text]
34. Picano E, Pellikka PA. Ultrasound of extravascular lung water: a new standard for pulmonary congestion. Eur Heart J. 2016 Jul 14;37(27):2097-104.[Abstract][Full Text]
35. Brennan JM, Ronan A, Goonewardena S, et al. Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic. Clin J Am Soc Nephrol. 2006 Jul;1(4):749-53.[Abstract]
36. Shehabi Y, Sterba M, Garrett PM; ProGUARD Study Investigators; ANZICS Clinical Trials Group. Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis. A randomized controlled trial. Am J Respir Crit Care Med. 2014 Nov 15;190(10):1102-10.[Abstract][Full Text]
37. Andriolo BN, Andriolo RB, Salomão R, et al. Effectiveness and safety of procalcitonin evaluation for reducing mortality in adults with sepsis, severe sepsis or septic shock. Cochrane Database Syst Rev. 2017 Jan 18;1(1):CD010959.[Abstract][Full Text]
38. Lam SW, Bauer SR, Fowler R, et al. Systematic review and meta-analysis of procalcitonin-guidance versus usual care for antimicrobial management in critically Ill patients: focus on subgroups based on antibiotic initiation, cessation, or mixed strategies. Crit Care Med. 2018 May;46(5):684-90.[Abstract]
39. Phua J, Koay ES, Lee KH. Lactate, procalcitonin, and amino-terminal pro-B-type natriuretic peptide versus cytokine measurements and clinical severity scores for prognostication in septic shock. Shock. 2008 Mar;29(3):328-33.[Abstract][Full Text]
40. Becker KL, Snider R, Nylen ES. Procalcitonin assay in systemic inflammation, infection, and sepsis: clinical utility and limitations. Crit Care Med. 2008 Mar;36(3):941-52.[Abstract]
41. Hooper L, Bunn DK, Abdelhamid A, et al. Water-loss (intracellular) dehydration assessed using urinary tests: how well do they work? Diagnostic accuracy in older people. Am J Clin Nutr. 2016 Jul;104(1):121-31.[Abstract][Full Text]
42. Balk RA. Severe sepsis and septic shock: definitions, epidemiology, and clinical manifestations. Crit Care Clin. 2000 Apr;16(2):179-92.[Abstract]
43. Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mechanisms. J Allergy Clin Immunol. 2002 Sep;110(3):341-8.[Abstract][Full Text]
44. Kramer GC, Kinsky MP, Prough DS, et al. Closed-loop control of fluid therapy for treatment of hypovolemia. J Trauma. 2008 Apr;64(4 Suppl):S333-41.[Abstract]
45. Roberts I, Blackhall K, Alderson P, et al. Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD001208.[Abstract][Full Text]
46. Lewis SR, Pritchard MW, Evans DJ, et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev. 2018 Aug 3;(8):CD000567.[Abstract][Full Text]
47. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018 Mar 1;378(9):829-39.[Abstract][Full Text]
48. Orbegozo Cortés D, Gamarano Barros T, Njimi H, et al. Crystalloids versus colloids: exploring differences in fluid requirements by systematic review and meta-regression. Anesth Analg. 2015 Feb;120(2):389-402.[Abstract]
49. Food and Drug Administration. Labeling changes on mortality, kidney injury, and excess bleeding with hydroxyethyl starch products. Jul 2021 [internet publication].[Full Text]
50. Zarychanski R, Abou-Setta AM, Turgeon AF, 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 Feb 20;309(7):678-88.[Abstract][Full Text]
51. European Medicines Agency. PRAC recommends suspending hydroxyethyl-starch solutions for infusion from the market. Feb 2022 [internet publication].[Full Text]
52. Kraut JA, Kurtz I. Treatment of acute non-anion gap metabolic acidosis. Clin Kidney J. 2015 Feb;8(1):93-9.[Abstract][Full Text]
53. Jung B, Martinez M, Claessens YE, et al. Diagnosis and management of metabolic acidosis: guidelines from a French expert panel. Ann Intensive Care. 2019 Aug 15;9(1):92.[Abstract][Full Text]
54. Kellum JA. Acute kidney injury. Crit Care Med. 2008 Apr;36(4 Suppl):S141-5.[Abstract]
55. National Institute for Health and Care Excellence. Intravenous fluid therapy in adults in hospital. May 2017 [internet publication].[Full Text]
56. Duggan JM. Personal view: crystalloid transfusion in acute gastrointestinal haemorrhage: is it beneficial? An historical perspective. Aliment Pharmacol Ther. 2006 Aug 1;24(3):493-6.[Abstract]
57. Hambly PR, Dutton RP. Excess mortality associated with the use of rapid infusion at a level 1 trauma center. Resuscitation. 1996 Apr;31(2):127-33.[Abstract]
58. Antonelli M, Levy M, Andrews PJ, et al. Hemodynamic monitoring in shock and implications for management: international consensus conference, Paris, France, 27-28 April 2006. Intensive Care Med. 2007 Apr;33(4):575-90.[Abstract]
59. Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am. 2008 May;92(3):491-509.[Abstract]
60. Guilabert P, Usúa G, Martín N, et al. Fluid resuscitation management in patients with burns: update. Br J Anaesth. 2016 Sep;117(3):284-96.[Abstract][Full Text]
61. Ipaktchi K, Arbabi S. Advances in burn critical care. Crit Care Med. 2006 Sep;34(9 Suppl):S239-44.[Abstract]
62. Cartotto R, Johnson LS, Savetamal A, et al. American burn association clinical practice guidelines on burn shock resuscitation. J Burn Care Res. 2024 May 6;45(3):565-89.[Abstract][Full Text]
63. American Burn Association. Advanced burn life support course. Chicago, IL: American Burn Association; 2018.
64. Voldby AW, Brandstrup B. Fluid therapy in the perioperative setting-a clinical review. J Intensive Care. 2016;4:27.[Abstract][Full Text]
65. Charache S, Ness PM. Transfusion therapy. In: Stobo JD, Hellmann DB, Ladenson PW, et al, eds. The principles and practice of medicine. 23rd ed. New York, NY: McGraw-Hill Professional; 1996:761-8.
66. Hellstern P, Muntean W, Schramm W, et al. Practical guidelines for the clinical use of plasma. Thromb Res. 2002 Oct 31;107 Suppl 1:S53-7.[Abstract]
67. Cable CA, Razavi SA, Roback JD, et al. RBC Transfusion strategies in the ICU: a concise review. Crit Care Med. 2019 Nov;47(11):1637-44.[Abstract][Full Text]
68. European Medicines Agency. European Medicines Agency recommends changes to the use of metoclopramide. July 2013 [internet publication].[Full Text]
69. Cooper DJ, Walley KR, Wiggs BR, et al. Bicarbonate does not improve hemodynamics in critically ill patients who have lactic acidosis: a prospective, controlled clinical study. Ann Intern Med. 1990 Apr 1;112(7):492-8.[Abstract]
70. Oddo M, Poole D, Helbok R, et al. Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations. Intensive Care Med. 2018 Apr;44(4):449-63.[Abstract]
71. Bagshaw SM, Townsend DR, McDermid RC. Disorders of sodium and water balance in hospitalized patients. Can J Anaesth. 2009 Feb;56(2):151-67.[Abstract]
72. Kristensen AK, Holler JG, Hallas J, et al. Is shock index a valid predictor of mortality in emergency department patients with hypertension, diabetes, high age, or receipt of beta- or calcium channel blockers? Ann Emerg Med. 2016 Jan;67(1):106-13.[Abstract]
