Is This Patient Hypovolemic?
Abstract
Objective To review, systematically, the physical diagnosis of hypovolemia in adults. Methods We searched MEDLINE (January 1966-November 1997), personal files, and bibliographies of textbooks on physical diagnosis and identified 10 studies investigating postural vital signs or the capillary refill time of healthy volunteers, some of whom underwent phlebotomy of up to 1150 mL of blood, and 4 studies of patients presenting to emergency departments with suspected hypovolemia, usually due to vomiting, diarrhea, or decreased oral intake. Results When clinicians evaluate adults with suspected blood loss, the most helpful physical findings are either severe postural dizziness (preventing measurement of upright vital signs) or a postural pulse increment of 30 beats/min or more. The presence of either finding has a sensitivity for moderate blood loss of only 22% (95% confidence interval [CI], 6%-48%) but a much greater sensitivity for large blood loss of 97% (95% CI, 91%-100%); the corresponding specificity is 98% (95% CI, 97%-99%). Supine hypotension and tachycardia are frequently absent, even after up to 1150 mL of blood loss (sensitivity, 33%; 95% CI, 21%-47%, for supine hypotension). The finding of mild postural dizziness has no proven value. In patients with vomiting, diarrhea, or decreased oral intake, the presence of a dry axilla supports the diagnosis of hypovolemia (positive likelihood ratio, 2.8; 95% CI, 1.4-5.4), and moist mucous membranes and a tongue without furrows argue…
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The clearest signs following excessive blood loss are a large postural pulse change (≥30 beats per minute) or severe postural dizziness leading to lack of ability to stand; these are 97% sensitive and 98% specific when blood loss is at least 630 mL, but much less sensitive at lower levels of blood loss.
“The clearest signs following excessive blood loss are a large postural pulse change (≥30 beats per minute) or severe postural dizziness leading to lack of ability to stand (273), which are 97% sensitive and 98% specific when blood loss is at least 630 mL, but much less sensitive at lower levels of blood loss.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [273]
Postural hypotension has little additional predictive value.
“The authors report that postural hypotension has little additional predictive value.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [273]
The results on signs following excessive blood loss were found in younger adults not taking beta-blockers, so sensitivity and specificity may vary in older persons.
“However, these results were found in younger adults not taking beta-blockers, so sensitivity and specificity may vary in older persons.”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [273]
A systematic review of signs associated with volume depletion after vomiting or diarrhea suggests that no signs are individually very useful.
“A systematic review of signs associated with volume depletion after vomiting or diarrhea suggests that no signs are individually very useful”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [273]
A person having at least four of the following seven signs is likely to have moderate to severe volume depletion: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes.
“but that a person having at least four of the following seven signs is likely to have moderate to severe volume depletion: confusion, non-fluent speech, extremity weakness, dry mucous membranes, dry tongue, furrowed tongue, sunken eyes”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [273]
The authors suggested that this form of diagnosis needs further assessment.
“However, the authors suggested that this form of diagnosis needs further assessment (273).”
From ESPEN practical guideline: Clinical nutrition and hydration in geriatrics (2022) · cites this paper as [273]
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References 80 · Cited by 583
- Authors
- McGee, S.
- Affiliations
- University of Washington (US)
- Corresponding author
- McGee, Steven
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 1999-03-17
- Volume
- 281
- Issue
- 11
- Pages
- 1022
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- OpenAlex
- W1978874230
- Cited by
- 583
- References
- 80
- Citations by year
- 2026: 11 · 2025: 15 · 2024: 20 · 2023: 21 · 2022: 23 · 2021: 24 · 2020: 21 · 2019: 26 · 2018: 19 · 2017: 24 · 2016: 31 · 2015: 33 · 2014: 24 · 2013: 26 · 2012: 32
- FWCI
- 11.64
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
- Keywords
- hypovolemia, physical examination, postural dizziness, capillary refill time, skin turgor, vomiting, diarrhea, blood loss, emergency department, sensitivity and specificity
- MeSH terms
- Aged, Blood Pressure, Dehydration, Female, Heart Rate, Hemorrhage, Humans, Hypotension, Male, Middle Aged, Physical Examination, Sensitivity and Specificity, Shock, Skin, Tachycardia, Models, Statistical, Tilt-Table Test
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