Expansion
History, observations, examination and charts together
Expansion
Signs of hypovolaemia
- Thirst, dry mucous membranes, reduced skin turgor
- Tachycardia, postural drop in blood pressure, narrow pulse pressure
- Low JVP, cool peripheries, prolonged capillary refill
- Reduced urine output (under 0.5 ml/kg/h), concentrated urine
- Rising urea disproportionate to creatinine, rising lactate
- Weight loss
Signs of fluid overload
- Raised JVP, peripheral and sacral oedema
- Bibasal crackles, orthopnoea, third heart sound
- Weight gain, ascites
- Positive fluid balance
Sources of information often neglected
- The fluid balance chart and the daily weight, which is the single most reliable measure of change
- Insensible losses: fever, sweating, tachypnoea, burns, stoma and drain output
Cautions: skin turgor is unreliable in the elderly; oedema indicates interstitial excess and can coexist with intravascular depletion, as in sepsis, hypoalbuminaemia and liver disease; and a patient can be simultaneously fluid overloaded and intravascularly dry, which is why oedema alone should never prevent fluid resuscitation in shock.
A passive leg raise or fluid challenge with reassessment is the most reliable bedside test of fluid responsiveness.