Mohammad Ahsan Ullah Khan Pathophysiology 14/10/2020

Dehydration – (Iso/Hyper/Hypoosmotic forms)

Dehydration - Dehydration is defined as the excessive loss of body water. The balance between fluid intake
and fluid loss (-ve water balance) from the body becomes greatly disproportionate during dehydration. The
severity of dehydration ranges from mild to severe and can be fatal when fluid losses exceed more than 15% of
total body water content.
Levels of Severity – Mild (2%), Moderate (5%), Severe (8%)
Pathophysiology – Total body water is divided into either extra or intracellular compartments.
Extracellular Compartment – contains 1/3 of the TBW.
- Consists of intravascular, interstitial and intercellular spaces.
- During dehydration fluid from EC is drained first, then intracellular.
Intracellular Compartment – contains 2/3 of the TBW
- Fluid loss is followed after extracellular fluid loss
- Results in cellular shrinkage and metabolic dysfunction.
Causes Of Dehydration
- Common causes of decreased water intake
- Chronic Illness, Fever, sickness
- Common in elderly, Impaired thirst mechanism: Adipsia/hypodipsia, symptom of decreased or
absent feelings of thirst. Involves increased osmolality concentration of solute in urine, leading to
stimulation of ADH secretion from hypothalamus to the kidneys. Increases water retention and
person becomes unable to feel thirst. Linked with diabetes insipidus as well. (20L/per day).
Anterior Hypothalamus in close proximity to the osmoreceptors which regulate ADH (primary
mechanisms of sodium/osmolar homeostasis is regulated. (4 types).
- Increased fluid loss
- Vomiting, diarrhoea, diuresis, sweating, working in harsh hot conditions.
Symptoms/Signs of Dehydration
- Normal signs – thirst, headaches and fatigue
- Mild – Constipation, dry mouth, low urine volumes
- Severe – Dry skin, sunken eyes, confusion, seizures, coma and even death.
- Hypovolemia – abnormally low extracellular fluid in the body, not the same as dehydration, due
to Tachycardia, orthostatic hypotension – decrease in systolic BP of 20mm/Hg or decrease in
diastolic BP of 10mm/Hg within 3 mins of standing as compared to sitting or supine position.
Hyper/Hypo/isonatremic dehydration
- Hyper = water loss > Sodium loss, serum Na+ conc. Increases (Na+ greater than 150mEq/L)
- Hypo = Sodium loss > water loss, serum Na+ conc. Decreases (Na+ less than 130mEq/L)
- Iso = water loss = Sodium loss, serum Na+ remains same (Na+ 130 – 150mEq/L)
- mEq/l, mEq = substance reactance to no. of H+ ions, L = fluid volume
- Normal serum osmolality range = 285-295 mOsm/kg
Hyperosmotic dehydration
- When water loss exceeds electrolyte loss, affects all body compartments
- ECF hyperosmolarity causes transfer of fluid from hypoosmolar cells to interstitium and plasma
- Blood osmolality is increased, water shift from intra to extracellular space.
- Causes: Fever – increase in respiratory rate, thus water loss
- Polyuria – increased water loss in urine, in line with diabetes mellitus/insipidus or diuretic use.
- Decreased water intake, excessive sweating, End-stage renal disease.
Lab Values
- Serum osmolality > 300 mOsm/kg,
- Urine vol decreases (unless cause is polyuria or diuretic use)
- Specific gravity is high and fractional excretion of sodium will also increase
- Increased erythrocytes, Hb and proteins but small sized erythrocytes, Haematocrit is lower or
slightly higher
Hypoosmotic dehydration

- Na+ loss is greater than water loss, decreasing serum osmolality.

- Causes shift of water from extracellular to intracellular space. Cells swell up and cerebral edema
may occur
Mohammad Ahsan Ullah Khan Pathophysiology 14/10/2020

- Can be acute or chronic – if Na+ loss more than 48hrs = chronic leading to neurological
symptoms: headaches, nausea, lethargy, coma or death.
- Causes: Addison’s disease – Chronic adrenocortical insufficiency
- Chronic Pyelonephritis increased by a salt-free diet
- Renal tubular acidosis – less aldosterone = less acid secretion in kidneys
- Diuretics: Loop diuretics – ascending limb of loops of Henle, thiazide
- Cystic fibrosis
Lab Values
- Serum/sodium + serum osmolality will be lower than normal range
- Urine specific gravity will be decreased, Urine sodium is decreased
Iso osmotic dehydration
- Proportional loss of water and sodium

- The loss of body fluids is limited to extracellular space.

- The cardiac output is decreased and as a result some changes of blood distribution in particular
organs occur. The blood flow in kidneys and skin decreases. Skin turgor and intraocular pressure
decreases as well. The failure of peripheral circulation – hypovolemic shock – is mostly
dangerous in isoosmotic dehydration. Loss 20% of blood or fluid.

- The diagnosis might be assisted with evaluation of haematocrit. The haematocrit increases asloss
of fluids is limited to ECF (except from posthaemorrhagic states).
- Newborns are most susceptible to this form of de- hydration. The total volume of ECF is small in
new- borns, and then common gastrointestinal problems associated with diarrhea can lead to a
relatively large loss of fluids.
- Causes: vomiting/diarrhoea, gastroenteritis
- Excessive sweating
- If not corrected can lead to – renal injury from muscle breakdown and lactic acidosis.
Lab Values
- Normal Osmolality 285-296 mOsm/kg, normal serum sodium 135-145mmol/L
- Urine vol. – oilguria low sodium excretion but high specific gravity
- Elevated liver and pancreatic enzymes
- Decreased glomerular filtration rate.
Complications of Dehydration
- Hypovolemic shock – low blood vol, end-organ damage via acidosis, kidney injury
- Seizures – sodium imbalances can cause abnormal neuronal excitability.
- Cardiac arrhythmias – Potassium imbalances – muscle breakdown, fatigue, weakness
- Heatstroke
- Kidney failure
- Thrombosis – increased blood viscosity can lead to venous thrombosis. Deep vein thrombosis.
Portal vein thrombosis. Pancreatitis increased by fever
- Coma and death – Low blood pressure in severe dehydration will decrease the blood supply to
the brain and could cause coma or death, particularly in elderly patients.
Treatment
- Obviously drink lots of water
- Intravenous fluids can be used for fluid replacement in unconscious patients with severe
dehydration.
- Plain water, sports drinks with electrolytes, and oral rehydration solutions are used for the
prevention and treatment of mild dehydration.
- HYPER - rate of 10 mEq/L/24hours is required to avoid cerebral edema and death as a
complication. 5% dextrose in 0.9% sodium chloride can be used with frequent monitoring of the
serum sodium every 4 hours. Hyperglycemia and hypocalcemia sometimes follow hypernatremic
dehydration, so serum glucose and calcium levels should be monitored closely.
- HYPO – acute cases involving seizures and coma, management of hyponatremia is accomplished
with hypertonic saline 3%. Correction at rate of 4-6 mEq/L/hour. In chronic hyponatremia,
sodium concentration should be done using normal saline 0.9% at a rate of 10-12 mEq/L/day
during the first 2 days. Rapid can lead to CN damage, quadriplegia, perm. Brain stem
Mohammad Ahsan Ullah Khan Pathophysiology 14/10/2020

- ISO - A fluid bolus - followed by maintenance therapy with 0.9% normal saline. 20 mL/kg of
isotonic sodium solution or lactated Ringer’s solution is given to restore hydration.