Subscribe for unlimited access to DynaMed content, CME/CE & MOC credit, and email alerts on content you follow.

Already subscribed? Sign in now

Learn more about CME

Dehydration and Hypovolemia in Adults

MoreVert
AddCircleOutlineFollow
ShareShare
AddCircleOutlineFollow
Follow
ShareShare
Share

General Information

Description

  • dehydration and hypovolemia are conditions of salt and water depletion which may occur concurrently or independently2,3

Definitions

Types

  • hypernatremic hypovolemia1
    • most common type of hypernatremia
    • occurs with water loss from sweat or diabetes insipidus; will result in hypernatremia (serum sodium > 145 mmol/L) if impaired thirst or access to water
    • both water and sodium lost, but water loss is greater than loss of sodium and potassium
    • loss of water and salt usually from kidneys (diuretics) or gastrointestinal tract (diarrhea)
    • presenting symptoms and signs will be those of hypovolemia such as tachycardia, orthostatic hypotension
    • volume depletion from hypotonic fluid losses commonly seen in patients with diarrhea and renal losses from diuretics
    • Reference - mdc26813151pPostgrad Med 2016;128(3):299OpenInNew
  • isotonic hypovolemia1
    • loss of fluids containing sodium plus potassium approximately equal to plasma sodium concentration
    • serum sodium 135-145 mmol/L (normal range)
    • occurs with hemorrhage and can be seen with diuretics and some gastrointestinal disorders
    • Reference - 7474224JAMA 1995 Nov 15;274(19):1552OpenInNew
  • hyponatremic hypovolemia1

References

General references used

  1. Reynolds RM, Padfield PL, Seckl JR. Disorders of sodium balance. BMJ. 2006 Mar 25;332(7543):702-5OpenInNewfull-textOpenInNew, commentary can be found in BMJ 2006 Apr 8;332(7545):853OpenInNew
  2. American Medical Directors Association (AMDA). Dehydration and fluid maintenance in the long-term care setting. AMDA 2009OpenInNew (reaffirmed 2012)
  3. Morley JE. Dehydration, Hypernatremia, and Hyponatremia. Clin Geriatr Med. 2015 Aug;31(3):389-99OpenInNew
  4. Sterns RH. Disorders of plasma sodium--causes, consequences, and correction. N Engl J Med. 2015 Jan 1;372(1):55-65OpenInNew, commentary can be found in N Engl J Med 2015 Mar 26;372(13):1268OpenInNew

Recommendation grading systems used

  • Task Force for Advanced Bleeding Care in Trauma (ABC-T) guideline grading system
    • Grade 1A
      • strong recommendation - benefits clearly outweigh risk and burdens, or vice versa
      • high-quality evidence based on randomized controlled trials without important limitations or overwhelming evidence from observational studies
    • Grade 1B
      • strong recommendation - benefits clearly outweigh risk and burdens, or vice versa
      • moderate-quality evidence based on randomized, controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies
    • Grade 1C
      • strong recommendation - benefits clearly outweigh risk and burdens, or vice versa
      • low-quality or very low-quality evidence based on observational studies or case series
    • Grade 2A
      • weak recommendation - benefits closely balanced with risks and burdens OR uncertainty on the estimates of benefits, risks, and burdens
      • high-quality evidence based on randomized controlled trials without important limitations or overwhelming evidence from observational studies
    • Grade 2B
      • weak recommendation - benefits closely balanced with risks and burdens OR uncertainty on the estimates of benefits, risks, and burdens
      • moderate-quality evidence based on randomized controlled trials with important limitations (inconsistent results, methodological flaws, indirect or imprecise) or exceptionally strong evidence from observational studies
    • Grade 2C
      • weak recommendation - benefits closely balanced with risks and burdens OR uncertainty on the estimates of benefits, risks, and burdens
      • low-quality or very low-quality evidence based on observational studies or case series
    • Reference - ABC-T European guideline on management of bleeding and coagulopathy following major trauma (23601765Crit Care 2013 Apr 19;17(2):R76OpenInNewfull-textOpenInNew), commentary can be found in 23905923Crit Care 2013 Jul 31;17(4):442OpenInNew
  • Kidney Disease: Improving Global Outcomes (KDIGO) recommendation grading system
    • strength of recommendation
      • Level 1 ("we recommend") - most patients should receive recommended course of action
      • Level 2 ("we suggest") - different choices will be appropriate for different patients, based on patient's values and preferences
      • Not Graded - topic does not allow adequate application of evidence, not meant to be interpreted as being stronger recommendations than Level 1 or 2
    • quality of evidence
      • Grade A - high-quality evidence, true effect lies close to that of estimate of effect
      • Grade B - moderate-quality evidence, true effect likely to be close to estimate of effect, but there is a possibility it is substantially different
      • Grade C - low-quality evidence, true effect may be substantially different from estimate of effect
      • Grade D - very low-quality evidence, estimate of effect very uncertain and often far from the truth
    • Reference - KDIGO clinical practice guideline on acute kidney injury (KDIGO 2012 Mar PDFPictureAsPdf)
  • Society of Critical Care Medicine (SCCM) uses Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)
    • strength of recommendation
      • Strong - benefits clearly outweigh risks and burdens (or vice versa) for most, if not all, patients
      • Weak - benefits and risks closely balanced and/or uncertain
      • Best practice statement - recommendation not conducive to GRADE process
    • quality of evidence
      • High - randomized trials without factors that reduce quality of evidence, or well-done observational studies with very large magnitude of effect
      • Moderate - downgraded randomized trials or upgraded observational studies
      • Low - well-done observational studies, or randomized trials with many limitations
      • Very low - case series or expert opinion
    • Reference - SCCM Surviving Sepsis Campaign 2016 international guideline on management of severe sepsis and septic shock (28101605Intensive Care Med 2017 Mar;43(3):304OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T904582, Dehydration and Hypovolemia in Adults; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T904582. Registration and login required.
  • KeyboardArrowRight

    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Definitions

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Likely risk factors

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Social history (SH)

    • KeyboardArrowRight

      Physical

      • General physical

      • Skin

      • HEENT

      • Neck

      • Extremities

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

    • Urine studies

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Fluid and electrolytes

      • Considerations for therapy

      • KeyboardArrowRight

        IV fluid selection

        • IV rehydration

        • Comparison of fluid choices

      • Determining fluid replacement needs

      • Hypodermoclysis

  • KeyboardArrowRight

    Complications

    • Complications

  • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Section Editor
Brad Denker MD
KeyboardArrowDown
Affiliations

Associate Professor of Medicine, Harvard Medical School; Massachusetts, United States; Clinical Director, Renal Division, Beth Israel Deaconess Medical Center; Massachusetts, United States

Conflicts of Interest

Dr. Denker declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
KeyboardArrowDown
Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
William Aird MD
KeyboardArrowDown
Affiliations

Deputy Editor of Hematology, Nephrology and Oncology, Dynamed; Massachusetts, United States; Professor of Medicine, Harvard Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Aird declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians
CheckCircle
Subscribe for unlimited access to DynaMed content.
Already subscribed? Sign in

top