Dehydration

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Dehydration
Cholera rehydration nurses.jpg
Nurses encourage a patient to drink an oral rehydration solution to treat dehydration caused by cholera.
Specialty Critical care medicine
Symptoms Increased thirst, tiredness, decreased urine, dizziness, headaches, and confusion [1]
Complications Low blood volume shock (hypovolemic shock), coma, seizures, urinary tract infection, kidney disease, heatstroke, hypernatremia, metabolic disease, [1] hypertension [2]
CausesLoss of body water
Risk factors Physical water scarcity, heatwaves, disease (most commonly from diseases that cause vomiting and/or diarrhea), exercise
TreatmentDrinking clean water
Medication Saline

In physiology, dehydration is a lack of total body water that disrupts metabolic processes. [3] It occurs when free water loss exceeds free water intake. This is usually due to excessive sweating, disease, or a lack of access to water. Mild dehydration can also be caused by immersion diuresis, which may increase risk of decompression sickness in divers.

Contents

Most people can tolerate a 3-4% decrease in total body water without difficulty or adverse health effects. A 5-8% decrease can cause fatigue and dizziness. Loss of over 10% of total body water can cause physical and mental deterioration, accompanied by severe thirst. Death occurs with a 15 and 25% loss of body water. [4] Mild dehydration usually resolves with oral rehydration, but severe cases may need intravenous fluids.

Dehydration can cause hypernatremia (high levels of sodium ions in the blood). This is distinct from hypovolemia (loss of blood volume, particularly blood plasma).

Chronic dehydration can cause kidney stones as well as the development of chronic kidney disease. [5] [6]

Signs and symptoms

Urine color as an indicator of hydration Urine Hydration chart.svg
Urine color as an indicator of hydration

The hallmarks of dehydration include thirst and neurological changes such as headaches, general discomfort, loss of appetite, nausea, decreased urine volume (unless polyuria is the cause of dehydration), confusion, unexplained tiredness, purple fingernails, and seizures. [8] The symptoms of dehydration become increasingly severe with greater total body water loss. A body water loss of 1-2%, considered mild dehydration, is shown to impair cognitive performance. [9] While in people over age 50, the body's thirst sensation diminishes with age, a study found that there was no difference in fluid intake between young and old people. [10] Many older people have symptoms of dehydration, with the most common being fatigue. [11] Dehydration contributes to morbidity in the elderly population, especially during conditions that promote insensible free water losses, such as hot weather.

Cause

Risk factors for dehydration include but are not limited to: exerting oneself in hot and humid weather, habitation at high altitudes, endurance athletics, elderly adults, infants, children and people living with chronic illnesses. [12] [13] [14] [15]

Dehydration can also come as a side effect from many different types of drugs and medications. [16]

In the elderly, blunted response to thirst or inadequate ability to access free water in the face of excess free water losses (especially hyperglycemia related) seem to be the main causes of dehydration. [17] Excess free water or hypotonic water can leave the body in two ways – sensible loss such as osmotic diuresis, sweating, vomiting and diarrhea, and insensible water loss, occurring mainly through the skin and respiratory tract. In humans, dehydration can be caused by a wide range of diseases and states that impair water homeostasis in the body. These occur primarily through either impaired thirst/water access or sodium excess. [18]

Mechanism

Diagram depicting the distribution of total body water into percentages of intracellular and extracellular fluid. Fluid composition of the body 1.3.png
Diagram depicting the distribution of total body water into percentages of intracellular and extracellular fluid.

Water makes up approximately 60% of the human body by mass. [20] Within the body, water is classified as intracellular fluid or extracellular fluid. Intracellular fluid refers to water that is contained within the cells. This consists of approximately 40% of the total body water. Fluid inside the cells has high concentrations of potassium, magnesium, phosphate, and proteins. [21] Extracellular fluid consists of all fluid outside of the cells, and it includes blood and interstitial fluid. This makes up approximately 60% of the total body water. The most common ions in extracellular fluid include sodium, chloride, and bicarbonate.

The concentration of dissolved molecules and ions in the fluid is described as Osmolarity and is measured in osmoles per liter (Osm/L). [21] When the body experiences a free water deficit, the concentration of solutes is increased. This leads to a higher serum osmolarity. When serum osmolarity is elevated, this is detected by osmoreceptors in the hypothalamus. These receptors trigger the release of antidiuretic hormone (ADH). [22] ADH resists dehydration by increasing water absorption in the kidneys and constricting blood vessels. It acts on the V2 receptors in the cells of the collecting tubule of the nephron to increase expression of aquaporin. In more extreme cases of low blood pressure, the hypothalamus releases higher amounts of ADH which also acts on V1 receptors. [23] These receptors cause contractions in the peripheral vascular smooth muscle. This increases systemic vascular resistance and raises blood pressure.

Diagnosis

Definition

Dehydration occurs when water intake does not replace free water lost due to normal physiologic processes, including breathing, urination, perspiration, or other causes, including diarrhea, and vomiting. Dehydration can be life-threatening when severe and lead to seizures or respiratory arrest, and also carries the risk of osmotic cerebral edema if rehydration is overly rapid. [24]

The term "dehydration" has sometimes been used incorrectly as a proxy for the separate, related condition of hypovolemia, which specifically refers to a decrease in volume of blood plasma. [3] The two are regulated through independent mechanisms in humans; [3] the distinction is important in guiding treatment. [25]

Physical examination

Ultrasound of the blood vessels of the neck that supports the diagnosis of severe dehydration [26]

Common exam findings of dehydration include dry mucous membranes, dry axillae, increased capillary refill time, sunken eyes, and poor skin turgor. [27] [11] More extreme cases of dehydration can lead to orthostatic hypotension, dizziness, weakness, and altered mental status. [28] Depending on the underlying cause of dehydration, other symptoms may be present as well. Excessive sweating from exercise may be associated with muscle cramps. Patients with gastrointestinal water loss from vomiting or diarrhea may also have fever or other systemic signs of infection.

The skin turgor test can be used to support the diagnosis of dehydration. The skin turgor test is conducted by pinching skin on the patient's body, in a location such as the forearm or the back of the hand, and watching to see how quickly it returns to its normal position. The skin turgor test can be unreliable in patients who have reduced skin elasticity, such as the elderly. [29]

Laboratory tests

While there is no single gold standard test to diagnose dehydration, evidence can be seen in multiple laboratory tests involving blood and urine. Serum osmolarity above 295 mOsm/kg is typically seen in dehydration due to free water loss. [11] A urinalysis, which is a test that performs chemical and microscopic analysis of urine, may find darker color or foul odor with severe dehydration. [30] Urinary sodium also provides information about the type of dehydration. For hyponatremic dehydration, such as from vomiting or diarrhea, urinary sodium will be less than 10mmol/L due to increased sodium retention by the kidneys in an effort to conserve water. [31] In dehydrated patients with sodium loss due to diuretics or renal dysfunction, urinary sodium may be elevated above 20 mmol/L. [32] Patients may also have elevated serum levels of blood urea nitrogen (BUN) and creatinine. Both of these molecules are normally excreted by the kidney, but when the circulating blood volume is low, the kidney can become injured. [33] This causes decreased kidney function and results in elevated BUN and creatinine in the serum. [34]

Prevention

For routine activities, thirst is normally an adequate guide to maintain proper hydration. [35] Minimum water intake will vary individually depending on weight, energy expenditure, age, sex, physical activity, environment, diet, and genetics. [36] [37] With exercise, exposure to hot environments, or a decreased thirst response, additional water may be required. In athletes in competition, drinking to thirst optimizes performance and safety, despite weight loss, and as of 2010, there was no scientific study showing that it is beneficial to stay ahead of thirst and maintain weight during exercise. [38]

In warm or humid weather, or during heavy exertion, water loss can increase markedly, because humans have a large and widely variable capacity for sweating. Whole-body sweat losses in men can exceed 2 L/h during competitive sport, with rates of 3–4 L/h observed during short-duration, high-intensity exercise in the heat. [39] When such large amounts of water are being lost through perspiration, electrolytes, especially sodium, are also being lost. [40]

In most athletes exercising and sweating for 4–5 hours with a sweat sodium concentration of less than 50 mmol/L, the total sodium lost is less than 10% of total body stores (total stores are approximately 2,500 mmol, or 58 g for a 70-kg person). [41] These losses appear to be well tolerated by most people. The inclusion of sodium in fluid replacement drinks has some theoretical benefits [41] and poses little or no risk, so long as these fluids are hypotonic (since the mainstay of dehydration prevention is the replacement of free water losses).

Treatment

The most effective treatment for minor dehydration is widely considered to be drinking water and reducing fluid loss. Plain water restores only the volume of the blood plasma, inhibiting the thirst mechanism before solute levels can be replenished. [42] Consumption of solid foods can also contribute to hydration. It is estimated approximately 22% of American water intake comes from food. [43] Urine concentration and frequency will return to normal as dehydration resolves. [44]

In some cases, correction of a dehydrated state is accomplished by the replenishment of necessary water and electrolytes (through oral rehydration therapy, or fluid replacement by intravenous therapy). As oral rehydration is less painful, non-invasive, inexpensive, and easier to provide, it is the treatment of choice for mild dehydration. [45] Solutions used for intravenous rehydration may be isotonic,hypertonic, or hypotonic depending on the cause of dehydration as well as the sodium concentration in the blood. [46] Pure water injected into the veins will cause the breakdown (lysis) of red blood cells (erythrocytes). [47]

When fresh water is unavailable (e.g. at sea or in a desert), seawater or drinks with significant alcohol concentration will worsen dehydration. Urine contains a lower solute concentration than seawater; this requires the kidneys to create more urine to remove the excess salt, causing more water to be lost than was consumed from seawater. [48] If a person is dehydrated and taken to a medical facility, IVs can also be used. [49]

For severe cases of dehydration where fainting, unconsciousness, or other severely inhibiting symptoms are present (the patient is incapable of standing upright or thinking clearly), emergency attention is required. Fluids containing a proper balance of replacement electrolytes are given orally or intravenously with continuing assessment of electrolyte status; complete resolution is normal in all but the most extreme cases. [50]

Prognosis

The prognosis for dehydration depends on the cause and extent of dehydration. Mild dehydration normally resolves with oral hydration. Chronic dehydration, such as from physically demanding jobs or decreased thirst, can lead to chronic kidney disease. [51] Elderly people with dehydration are at higher risk of confusion, urinary tract infections, falls, and even delayed wound healing. [52] In children with mild to moderate dehydration, oral hydration is adequate for a full recovery. [53]

See also

Related Research Articles

<span class="mw-page-title-main">Diabetes insipidus</span> Condition characterized by large amounts of dilute urine and increased thirst

Diabetes insipidus (DI) is a condition characterized by large amounts of dilute urine and increased thirst. The amount of urine produced can be nearly 20 liters per day. Reduction of fluid has little effect on the concentration of the urine. Complications may include dehydration or seizures.

Hyponatremia or hyponatraemia is a low concentration of sodium in the blood. It is generally defined as a sodium concentration of less than 135 mmol/L (135 mEq/L), with severe hyponatremia being below 120 mEq/L. Symptoms can be absent, mild or severe. Mild symptoms include a decreased ability to think, headaches, nausea, and poor balance. Severe symptoms include confusion, seizures, and coma; death can ensue.

<span class="mw-page-title-main">Fluid replacement</span> Medical practice of replenishing bodily fluid

Fluid replacement or fluid resuscitation is the medical practice of replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes. Fluids can be replaced with oral rehydration therapy (drinking), intravenous therapy, rectally such as with a Murphy drip, or by hypodermoclysis, the direct injection of fluid into the subcutaneous tissue. Fluids administered by the oral and hypodermic routes are absorbed more slowly than those given intravenously.

<span class="mw-page-title-main">Sports drink</span> Oral electrolytic infusion

Sports drinks, also known as electrolyte drinks, are functional beverages whose stated purpose is to help athletes replace water, electrolytes, and energy before, during and especially after training or competition. The evidence is lacking pertaining to the efficacy of use of commercial sports drinks for sports and fitness performance.

<span class="mw-page-title-main">Thirst</span> Craving for potable fluids experienced by animals

Thirst is the craving for potable fluids, resulting in the basic instinct of animals to drink. It is an essential mechanism involved in fluid balance. It arises from a lack of fluids or an increase in the concentration of certain osmolites, such as sodium. If the water volume of the body falls below a certain threshold or the osmolite concentration becomes too high, structures in the brain detect changes in blood constituents and signal thirst.

Heat exhaustion is a heat-related illness characterized by the body's inability to effectively cool itself, typically occurring in high ambient temperatures or during intense physical exertion. In heat exhaustion, core body temperature ranges from 37 °C to 40 °C. Symptoms include profuse sweating, weakness, dizziness, headache, nausea, and lowered blood pressure, resulting from dehydration and serum electrolyte depletion. Heat-related illnesses lie on a spectrum of severity, where heat exhaustion is considered less severe than heat stroke but more severe than heat cramps and heat syncope.

<span class="mw-page-title-main">Electrolyte imbalance</span> Abnormality in the concentration of electrolytes in the body

Electrolyte imbalance, or water-electrolyte imbalance, is an abnormality in the concentration of electrolytes in the body. Electrolytes play a vital role in maintaining homeostasis in the body. They help to regulate heart and neurological function, fluid balance, oxygen delivery, acid–base balance and much more. Electrolyte imbalances can develop by consuming too little or too much electrolyte as well as excreting too little or too much electrolyte. Examples of electrolytes include calcium, chloride, magnesium, phosphate, potassium, and sodium.

Hypernatremia, also spelled hypernatraemia, is a high concentration of sodium in the blood. Early symptoms may include a strong feeling of thirst, weakness, nausea, and loss of appetite. Severe symptoms include confusion, muscle twitching, and bleeding in or around the brain. Normal serum sodium levels are 135–145 mmol/L. Hypernatremia is generally defined as a serum sodium level of more than 145 mmol/L. Severe symptoms typically only occur when levels are above 160 mmol/L.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH), also known as the syndrome of inappropriate antidiuresis (SIAD), is characterized by a physiologically inappropriate release of antidiuretic hormone (ADH) either from the posterior pituitary gland, or an abnormal non-pituitary source. Unsuppressed ADH causes a physiologically inappropriate increase in solute-free water being reabsorbed by the tubules of the kidney to the venous circulation leading to hypotonic hyponatremia.

Hyperchloremia is an electrolyte disturbance in which there is an elevated level of chloride ions in the blood. The normal serum range for chloride is 96 to 106 mEq/L, therefore chloride levels at or above 110 mEq/L usually indicate kidney dysfunction as it is a regulator of chloride concentration. As of now there are no specific symptoms of hyperchloremia; however, it can be influenced by multiple abnormalities that cause a loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities are caused by diarrhea, vomiting, increased sodium chloride intake, renal dysfunction, diuretic use, and diabetes. Hyperchloremia should not be mistaken for hyperchloremic metabolic acidosis as hyperchloremic metabolic acidosis is characterized by two major changes: a decrease in blood pH and bicarbonate levels, as well as an increase in blood chloride levels. Instead those with hyperchloremic metabolic acidosis are usually predisposed to hyperchloremia.

<span class="mw-page-title-main">Water intoxication</span> Potentially fatal overhydration

Water intoxication, also known as water poisoning, hyperhydration, overhydration, or water toxemia, is a potentially fatal disturbance in brain functions that can result when the normal balance of electrolytes in the body is pushed outside safe limits by excessive water intake.

Cerebral salt-wasting syndrome (CSWS), also written cerebral salt wasting syndrome, is a rare endocrine condition featuring a low blood sodium concentration and dehydration in response to injury (trauma) or the presence of tumors in or surrounding the brain. In this condition, the kidney is functioning normally but excreting excessive sodium. The condition was initially described in 1950. Its cause and management remain controversial. In the current literature across several fields, including neurology, neurosurgery, nephrology, and critical care medicine, there is controversy over whether CSWS is a distinct condition, or a special form of syndrome of inappropriate antidiuretic hormone secretion (SIADH).

<span class="mw-page-title-main">Oral rehydration therapy</span> Type of fluid replacement used to prevent and treat dehydration

Oral rehydration therapy (ORT) is a type of fluid replacement used to prevent and treat dehydration, especially due to diarrhea. It involves drinking water with modest amounts of sugar and salts, specifically sodium and potassium. Oral rehydration therapy can also be given by a nasogastric tube. Therapy can include the use of zinc supplements to reduce the duration of diarrhea in infants and children under the age of 5. Use of oral rehydration therapy has been estimated to decrease the risk of death from diarrhea by up to 93%.

Fluid balance is an aspect of the homeostasis of organisms in which the amount of water in the organism needs to be controlled, via osmoregulation and behavior, such that the concentrations of electrolytes in the various body fluids are kept within healthy ranges. The core principle of fluid balance is that the amount of water lost from the body must equal the amount of water taken in; for example, in humans, the output must equal the input. Euvolemia is the state of normal body fluid volume, including blood volume, interstitial fluid volume, and intracellular fluid volume; hypovolemia and hypervolemia are imbalances. Water is necessary for all life on Earth. Humans can survive for 4 to 6 weeks without food but only for a few days without water.

Nephrogenic diabetes insipidus, recently renamed arginine vasopressin resistance (AVP-R) and previously known as renal diabetes insipidus, is a form of diabetes insipidus primarily due to pathology of the kidney. This is in contrast to central or neurogenic diabetes insipidus, which is caused by insufficient levels of vasopressin. Nephrogenic diabetes insipidus is caused by an improper response of the kidney to vasopressin, leading to a decrease in the ability of the kidney to concentrate the urine by removing free water.

<span class="mw-page-title-main">Urine specific gravity</span> Topic related to human medicine

Specific gravity, in the context of clinical pathology, is a urinalysis parameter commonly used in the evaluation of kidney function and can aid in the diagnosis of various renal diseases.

<span class="mw-page-title-main">Sodium in biology</span> Use of sodium by organisms

Sodium ions are necessary in small amounts for some types of plants, but sodium as a nutrient is more generally needed in larger amounts by animals, due to their use of it for generation of nerve impulses and for maintenance of electrolyte balance and fluid balance. In animals, sodium ions are necessary for the aforementioned functions and for heart activity and certain metabolic functions. The health effects of salt reflect what happens when the body has too much or too little sodium. Characteristic concentrations of sodium in model organisms are: 10 mM in E. coli, 30 mM in budding yeast, 10 mM in mammalian cell and 100 mM in blood plasma.

<span class="mw-page-title-main">Adipsia</span> Medical condition

Adipsia, also known as hypodipsia, is a symptom of inappropriately decreased or absent feelings of thirst. It involves an increased osmolality or concentration of solute in the urine, which stimulates secretion of antidiuretic hormone (ADH) from the hypothalamus to the kidneys. This causes the person to retain water and ultimately become unable to feel thirst. Due to its rarity, the disorder has not been the subject of many research studies.

<span class="mw-page-title-main">Diuretic</span> Substance that promotes the production of urine

A diuretic is any substance that promotes diuresis, the increased production of urine. This includes forced diuresis. A diuretic tablet is sometimes colloquially called a water tablet. There are several categories of diuretics. All diuretics increase the excretion of water from the body, through the kidneys. There exist several classes of diuretic, and each works in a distinct way. Alternatively, an antidiuretic, such as vasopressin, is an agent or drug which reduces the excretion of water in urine.

<span class="mw-page-title-main">Salt poisoning</span> Intoxication from excessive intake of sodium

Salt poisoning is an intoxication resulting from the excessive intake of sodium either in solid form or in solution. Salt poisoning sufficient to produce severe symptoms is rare, and lethal salt poisoning is possible but even rarer. The lethal dose of table salt is roughly 0.5–1 gram per kilogram of body weight.

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