1. AdvertisementHome Page > News & Publications > Journals > American Family PhysicianID Number Last Name/Password Remember Me Log-in HelpAdvanced Search ID Number Last Name/PasswordundefinedRemember Me Log-in HelpAdvertisementARTICLE TOOLS Please note: The American Family Physician Web archiveextends from 1998 to the present. Enhanced features areEmail this page available for content published after 2000.Share this pageAFP CME QuizSEARCH AFPTips from Other JournalsAFP Advanced SearchIndex | NextAFP AT A GLANCEEstablishing a Bedside Diagnosis ofPast IssuesAnnual IndexesHypovolemiaVarious signs, including postural vital signs, capillary refill time, skin turgor andCME Quizmoistness of the axillae, tongue and mucous membranes, may be used in the assessmentDept Collectionsof patients with suspected hypovolemia. McGee and colleagues conducted a literatureEBM Toolkit review to identify which, if any, signs and symptoms were reliable in the clinicalAbout AFP evaluation of volume depletion and dehydration.Information forAdvertisers A MEDLINE search was used to retrieve articles on the bedside diagnosis ofhypovolemia. Some studies were of patients with known amounts of blood loss, whileSubscriptionsothers were of patients who presented to emergency departments and were suspected ofContact AFPhaving hypovolemia as a result of symptoms such as vomiting, diarrhea and decreasedCareers oral intake.As far as the reliability of postural vital signs in the diagnosis of hypovolemia isconcerned, a review of 25 studies of postural vital signs in more than 3,500normovolemic 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. Innormovolemic adults, a postural pulse increment of more than 30 beats per minuteaffects only about 2 to 4 percent of persons. Studies suggest that postural hypotensionoccurs in up to 10 percent of normovolemic adults younger than 65 years and in 11 to30 percent of adults older than 65 years. The authors found that the most helpfulphysical findings in the evaluation of patients with suspected blood loss were severepostural dizziness (preventing measurement of vital signs with the patient upright) and apostural pulse increase of 30 beats per minute or more. Mild postural dizziness had novalue in the diagnosis of hypovolemia.Normal capillary refill time ranges from two seconds in children and adult men to threeseconds in adult women and four seconds in the elderly. One study revealed that aprolonged refill time does not accurately predict 450 mL of blood loss. This sign wasfound 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 ofhypovolemia, studies suggest that this is an insensitive physical sign, with only a 50percent sensitivity. Signs that point away from hypovolemia are moist mucousmembranes, 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 thepostural pulse or severe postural dizziness (precluding upright vital signs) is required todiagnose hypovolemia related to blood loss, although these findings are often absent inthe setting of moderate blood loss. The literature review indicated that few findingshave proven reliability in the diagnosis of hypovolemia related to diarrhea, vomitingand decreased oral intake. Decreased capillary refill time and poor skin turgor have

2. been shown not to be of diagnostic value. Thus, the authors state that physicians shouldnot hesitate to order serum electrolyte, blood urea nitrogen and creatininedeterminations if hypovolemia is suspected.GRACE BROOKE HUFFMAN, M.D.McGee S, et al. Is this patient hypovolemic? JAMA March 17,1999;281:1022-9.Index | NextCopyright 1999 by the American Academy of Family Physicians.This content is owned by the AAFP. A person viewing it online may make oneprintout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied,printed, stored, transmitted or reproduced in any medium, whether now known or laterinvented, except as authorized in writing by the AAFP. More Tips | September 15, 1999 Contents | AFP Home Page | AAFP Home | Search