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hypervolemia (extracellular volume overload)
Etiology:
1) Na+ retention
a) renal failure
1] acute renal failure
2] chronic renal failure
b) endocrine causes generally not associated with edema
1] hyperaldosteronism
2] syndrome of inappropriate antidiuretic hormone (SIADH)
3] Cushing's syndrome
2) decreased effective circulating volume
a) diminished cardiac output
1] myocardial infarction
2] cardiomyopathy
3] hypertensive emergency
4] cor pulmonale
b) cirrhosis
c) nephrotic syndrome
3) excessive fluid administration
a) IV fluids
b) parenteral nutrition
c) sodium-containing penicillins
Clinical manifestations:
1) fatigue
2) dependent edema
3) dyspnea*
a) exertional dyspnea
b) paroxysmal nocturnal dyspnea
c) resting dyspnea
d) orthopnea
5) tachypnea
6) tachycardia
7) pulmonary crackles
8) S3 heart sound
9) increased weight
10) jugular venous distension (JVD)*
11) hepatojugular reflex
12) pleural effusion
13) subungual edema
14) hypotension
15) low pulse pressure
16) early satiety
17) signs & symptoms resulting from specific etiology
Laboratory:
1) serum chemistries
a) urea nitrogen increased in renal failure, normal in nephrotic syndrome
b) creatinine increased in renal failure, normal in nephrotic syndrome
c) albumin decreased in nephrotic syndrome & cirrhosis
d) K+ decreased in hyperaldosteronism
e) bilirubin increased in cirrhosis
f) cholesterol decreased in cirrhosis, increased in nephrotic syndrome
2) urinalysis
a) specific gravity
b) protein
3) fractional excretion of sodium (FENA) or chloride
4) 24 hour urine protein
Radiology:
1) chest X-ray
a) pulmonary vascular redistribution*
b) may show pulmonary edema
2) echocardiogram
3) abdominal ultrasound
* most important indicators of volume overload
Indications:
1) pericardial tamponade
2) venous lymphatic obstruction
3) venous thrombosis
4) idiopathic lymphedema
Management:
1) Na+ restriction
2) water restriction
3) diuresis
4) hemodynamic monitoring if indicated
5) discontinue medications that interfere with Na+ secretion of cardiac output
a) non-steroidal anti-inflammatory drugs (NSAIDs)
b) negative inotropes
6) removal of fluid may provide temporary relief of symptoms & diagnostic information
a) paracentesis
b) thoracentesis
c) hemodialysis
7) treatment of pulmonary edema
a) oxygen
b) nitrates
c) morphine
8) bedrest is the safest diuretic
9) treat underlying etiology when patient is hemodynamically stable
Related
cardiomyopathy
Cushing's syndrome; hypercortisolism; hyperadrenocorticism; pluriglandular syndrome
heart failure (HF)
hyperaldosteronism
hypertension (HTN, high blood pressure, HBP)
nephrotic syndrome
renal failure; kidney failure
syndrome of inappropriate antidiuretic hormone; SIADH; nephrogenic syndrome of inappropriate antidiuresis; NSIAD
Specific
transfusion-associated volume overload; transfusion-associated circulatory overload
General
fluid imbalance; water imbalance
References
- Saunders Manual of Medical Practice, Rakel (ed), WB Saunders,
Philadelphia, 1996, pg 684-85
- Medical Knowledge Self Assessment Program (MKSAP) 11, 15,
American College of Physicians, Philadelphia 1998, 2009