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56 Establishing A Bedside Diagnosis Of Hypovolemia
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AFP AT A GLANCE
Establishing a Bedside Diagnosis of
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Hypovolemia
Various signs, including postural vital signs, capillary refill time, skin turgor and
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moistness of the axillae, tongue and mucous membranes, may be used in the assessment
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of patients with suspected hypovolemia. McGee and colleagues conducted a literature
EBM Toolkit review to identify which, if any, signs and symptoms were reliable in the clinical
About AFP evaluation of volume depletion and dehydration.
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Advertisers A MEDLINE search was used to retrieve articles on the bedside diagnosis of
hypovolemia. Some studies were of patients with known amounts of blood loss, while
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others were of patients who presented to emergency departments and were suspected of
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having hypovolemia as a result of symptoms such as vomiting, diarrhea and decreased
Careers oral intake.
As far as the reliability of postural vital signs in the diagnosis of hypovolemia is
concerned, a review of 25 studies of postural vital signs in more than 3,500
normovolemic persons revealed that a postural pulse increase of 30 per minute or more
(the common threshold used in clinical studies) had a specificity of 96 percent. In
normovolemic adults, a postural pulse increment of more than 30 beats per minute
affects only about 2 to 4 percent of persons. Studies suggest that postural hypotension
occurs in up to 10 percent of normovolemic adults younger than 65 years and in 11 to
30 percent of adults older than 65 years. The authors found that the most helpful
physical findings in the evaluation of patients with suspected blood loss were severe
postural dizziness (preventing measurement of vital signs with the patient upright) and a
postural pulse increase of 30 beats per minute or more. Mild postural dizziness had no
value in the diagnosis of hypovolemia.
Normal capillary refill time ranges from two seconds in children and adult men to three
seconds in adult women and four seconds in the elderly. One study revealed that a
prolonged refill time does not accurately predict 450 mL of blood loss. This sign was
found to have a 6 percent sensitivity and a 93 percent specificity.
While the literature indicates that the finding of a dry axilla increases the probability of
hypovolemia, studies suggest that this is an insensitive physical sign, with only a 50
percent sensitivity. Signs that point away from hypovolemia are moist mucous
membranes, lack of sunken eyes and lack of furrows on the tongue.
The authors conclude that a large increase (more than 30 beats per minute) in the
postural pulse or severe postural dizziness (precluding upright vital signs) is required to
diagnose hypovolemia related to blood loss, although these findings are often absent in
the setting of moderate blood loss. The literature review indicated that few findings
have proven reliability in the diagnosis of hypovolemia related to diarrhea, vomiting
and decreased oral intake. Decreased capillary refill time and poor skin turgor have
