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Deißler L, Wirth R, Frilling B, Janneck M, Rösler A. Hydration Status Assessment in Older Patients. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:663-669. [PMID: 37583084 PMCID: PMC10644957 DOI: 10.3238/arztebl.m2023.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Hydration disturbances are common in old age: the reported prevalence of dehydration in elderly patients ranges from 19% to 89%, depending on the definition and the population in question. However, the clinical assessment of patients' hydration status is difficult. In this review, we discuss the diagnostic value of currently used methods that may or may not be suitable for assessing older patients' hydration status. METHODS We conducted a selective literature search for relevant studies concerning patients aged 65 and above. Of the 355 articles retrieved by the initial search, a multistep selection process yielded 30 that were suitable for inclusion in this review. RESULTS 107 different methods for the diagnostic assessment of dehydration in older persons were evaluated on the basis of the reviewed publications. High diagnostic value, especially for the determination of hyperosmolar dehydration, was found for serum osmolality, serum sodium concentration, inferior vena cava ultrasonography, a history (from the patient or another informant) of not drinking between meals, and axillary dryness. On the other hand, a variety of clinical signs such as a positive skin turgor test, sunken eyes, dry mouth, tachycardia, orthostatic dysregulation, and dark urine were found to be of inadequate diagnostic value. CONCLUSION Only five of the 107 methods considered appear to be suitable for determining that a patient is dehydrated. Thus, the available scientific evidence indicates that all clinicians should critically reconsider their own techniques for assessing hydration status in elderly patients. To optimize the clinical assessment of patients' hydration status, there seems to be a need for the rejection of unsuitable methods in favor of either newly developed criteria or of a combination of the best criteria already in use.
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Affiliation(s)
- Linda Deißler
- Medical Faculty, University of Hamburg, Hamburg, Germany
| | - Rainer Wirth
- Marien Hospital Herne, University Hospital of the Ruhr University Bochum, Herne, Germany
| | - Birgit Frilling
- Albertinen House – Center for Geriatrics and Gerontology, Hamburg, Germany
| | | | - Alexander Rösler
- Department of Geriatrics, Agaplesion Bethesda Hospital HH-Bergedorf, Hamburg, Germany
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Banjade P, Subedi A, Ghamande S, Surani S, Sharma M. Systemic Venous Congestion Reviewed. Cureus 2023; 15:e43716. [PMID: 37724234 PMCID: PMC10505504 DOI: 10.7759/cureus.43716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Accurate determination of intravascular volume status is challenging in acutely ill patients. Favorable patient outcome is vital to correctly identify intravascular volume depletion and avoid systemic venous congestion. Most of the conventional means of hemodynamic monitoring in the acute healthcare setting are geared toward addressing the cardiac output and maintaining an optimum mean arterial pressure. While assessing and maintaining cardiac output in an acutely ill patient is very important, a venous congestion cascade is often overlooked, which can negatively affect the intraabdominal end organs. The prospect of using point-of-care ultrasound (POCUS) to determine systemic venous congestion could be a potentially handy tool for clinicians. Venous excess ultrasound score (VExUS) has also been utilized by clinicians as a semi-quantitative assessment tool to assess fluid status. This review aims to discuss the potential role of POCUS and VExUS scores in determining systemic venous congestion through a narrative review of recently published literature.
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Affiliation(s)
- Prakash Banjade
- Department of General Medicine, Manipal College of Medical Sciences, Pokhara, NPL
| | - Ashish Subedi
- Department of Internal Medicine, Gandaki Medical College, Kathmandu, NPL
| | - Shekhar Ghamande
- Department of Pulmonary, Critical Care and Sleep Medicine, Baylor Scott and White Medical Center, Temple, USA
| | - Salim Surani
- Department of Anesthesiology, Mayo Clinic, Rochester, USA
- Department of Medicine, Texas Agricultural and Mechanical (A&M) University, College Station, USA
- Department of Medicine, University of North Texas, Dallas, USA
- Department of Internal Medicine, Pulmonary Associates, Corpus Christi, USA
- Department of Clinical Medicine, University of Houston, Houston, USA
| | - Munish Sharma
- Department of Pulmonary and Critical Care Medicine, Baylor Scott and White Medical Center, Temple, USA
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Pazos-Guerra M, Ruiz-Sánchez JG, Pérez-Candel X, López-Nevado C, Hernández-Olmeda F, Cuesta-Hernández M, Martín-Sánchez J, Calle-Pascual AL, Runkle-de la Vega I. Inappropriate therapy of euvolemic hyponatremia, the most frequent type of hyponatremia in SARS-CoV-2 infection, is associated with increased mortality in COVID-19 patients. Front Endocrinol (Lausanne) 2023; 14:1227059. [PMID: 37560297 PMCID: PMC10408442 DOI: 10.3389/fendo.2023.1227059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/30/2023] [Indexed: 08/11/2023] Open
Abstract
Introduction Admission hyponatremia, frequent in patients hospitalized for COVID-19, has been associated with increased mortality. However, although euvolemic hyponatremia secondary to the Syndrome of Inappropriate Antidiuresis (SIAD) is the single most common cause of hyponatremia in community-acquired pneumonia (CAP), a thorough and rigorous assessment of the volemia of hyponatremic COVID-19 subjects has yet to be described. We sought to identify factors contributing to mortality and hospital length-of-stay (LOS) in hospitalized COVID-19 patients admitted with hyponatremia, taking volemia into account. Method Retrospective study of 247 patients admitted with COVID-19 to a tertiary hospital in Madrid, Spain from March 1st through March 30th, 2020, with a glycemia-corrected serum sodium level (SNa) < 135 mmol/L. Variables were collected at admission, at 2nd-3rd day of hospitalization, and ensuing days when hyponatremia persisted. Admission volemia (based on both physical and analytical parameters), therapy, and its adequacy as a function of volemia, were determined. Results Age: 68 years [56-81]; 39.9% were female. Median admission SNa was 133 mmol/L [131- 134]. Hyponatremia was mild (SNa 131-134 mmol/L) in 188/247 (76%). Volemia was available in 208/247 patients; 57.2% were euvolemic and the rest (42.8%) hypovolemic. Hyponatremia was left untreated in 154/247 (62.3%) patients. Admission therapy was not concordant with volemia in 43/84 (51.2%). In fact, the majority of treated euvolemic patients received incorrect therapy with isotonic saline (37/41, 90.2%), whereas hypovolemics did not (p=0.001). The latter showed higher mortality rates than those receiving adequate or no therapy (36.7% vs. 19% respectively, p=0.023). The administration of isotonic saline to euvolemic hyponatremic subjects was independently associated with an elevation of in-hospital mortality (Odds Ratio: 3.877, 95%; Confidence Interval: 1.25-12.03). Conclusion Hyponatremia in COVID-19 is predominantly euvolemic. Isotonic saline infusion therapy in euvolemic hyponatremic COVID-19 patients can lead to an increased mortality rate. Thus, an exhaustive and precise volemic assessment of the hyponatremic patient with CAP, particularly when due to COVID-19, is mandatory before instauration of therapy, even when hyponatremia is mild.
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Affiliation(s)
- Mario Pazos-Guerra
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Jorge Gabriel Ruiz-Sánchez
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria Fundación Jiménez-Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Xavier Pérez-Candel
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Celia López-Nevado
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Fernando Hernández-Olmeda
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Martin Cuesta-Hernández
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Javier Martín-Sánchez
- Medicine II Department, Universidad Complutense de Madrid, Madrid, Spain
- Emergency Department, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Alfonso Luis Calle-Pascual
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
- Medicine II Department, Universidad Complutense de Madrid, Madrid, Spain
| | - Isabelle Runkle-de la Vega
- Department of Endocrinology and Nutrition, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Medicine II Department, Universidad Complutense de Madrid, Madrid, Spain
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Mustafa OG, Haq M, Dashora U, Castro E, Dhatariya KK. Management of Hyperosmolar Hyperglycaemic State (HHS) in Adults: An updated guideline from the Joint British Diabetes Societies (JBDS) for Inpatient Care Group. Diabet Med 2023; 40:e15005. [PMID: 36370077 PMCID: PMC10107355 DOI: 10.1111/dme.15005] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022]
Abstract
Hyperosmolar Hyperglycaemic State (HHS) is a medical emergency associated with high mortality. It occurs less frequently than diabetic ketoacidosis (DKA), affects those with pre-existing/new type 2 diabetes mellitus and increasingly affecting children/younger adults. Mixed DKA/HHS may occur. The JBDS HHS care pathway consists of 3 themes (clinical assessment and monitoring, interventions, assessments and prevention of harm) and 5 phases of therapy (0-60 min, 1-6, 6-12, 12-24 and 24-72 h). Clinical features of HHS include marked hypovolaemia, osmolality ≥320 mOsm/kg using [(2×Na+ ) + glucose+urea], marked hyperglycaemia ≥30 mmol/L, without significant ketonaemia (≤3.0 mmol/L), without significant acidosis (pH >7.3) and bicarbonate ≥15 mmol/L. Aims of the therapy are to improve clinical status/replace fluid losses by 24 h, gradual decline in osmolality (3.0-8.0 mOsm/kg/h to minimise the risk of neurological complications), blood glucose 10-15 mmol/L in the first 24 h, prevent hypoglycaemia/hypokalaemia and prevent harm (VTE, osmotic demyelination, fluid overload, foot ulceration). Underlying precipitants must be identified and treated. Interventions include: (1) intravenous (IV) 0.9% sodium chloride to restore circulating volume (fluid losses 100-220 ml/kg, caution in elderly), (2) fixed rate intravenous insulin infusion (FRIII) should be commenced once osmolality stops falling with fluid replacement unless there is ketonaemia (FRIII should be commenced at the same time as IV fluids). (3) glucose infusion (5% or 10%) should be started once glucose <14 mmol/L and (4) potassium replacement according to potassium levels. HHS resolution criteria are: osmolality <300 mOsm/kg, hypovolaemia corrected (urine output ≥0.5 ml/kg/h), cognitive status returned to pre-morbid state and blood glucose <15 mmol/L.
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Affiliation(s)
- Omar G. Mustafa
- Department of diabetesKing's College Hospital NHS Foundation TrustLondonUK
- King's College LondonLondonUK
| | - Masud Haq
- Maidstone and Tunbridge Wells NHS TrustTunbridge WellsUK
| | - Umesh Dashora
- Conquest Hospital, Easdt Sussex Healthcare NHS TrustThe Ridge St Leonards on SeaUK
| | - Erwin Castro
- Conquest Hospital, Easdt Sussex Healthcare NHS TrustThe Ridge St Leonards on SeaUK
| | - Ketan K. Dhatariya
- Elsie Bertram Diabetes CentreNorfolk and Norwich University Hospitals NHS Foundation TrustNorwichUK
- Norwich Medicine SchoolUniversity of East AngliaNorwichUK
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Supakul S, Nishikawa Y, Teramura M, Takase T. Short-Term Treatment with Empagliflozin Resulted in Dehydration and Cardiac Arrest in an Elderly Patient with Specific Complications: A Case Report and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060815. [PMID: 35744078 PMCID: PMC9227880 DOI: 10.3390/medicina58060815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/06/2022] [Accepted: 06/15/2022] [Indexed: 02/07/2023]
Abstract
Empagliflozin is a sodium-glucose cotransporter-2 inhibitor widely used in the treatment of diabetes mellitus and heart failure. Our case study involved a 68-year-old patient who was admitted to the hospital because of a cerebral infarction. The patient was simultaneously diagnosed with diabetes mellitus and heart failure, for which empagliflozin was initiated. However, food and fluid intake were reduced due to poor appetite. In addition to the side effects of empagliflozin, the patient developed severe dehydration and cardiac arrest. Careful assessment of dehydration and preventive water intake is recommended in elderly patients and those with neurological deficits, especially when receiving empagliflozin.
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Affiliation(s)
- Sopak Supakul
- Graduate School of Medicine, Keio University, Tokyo 160-8582, Japan;
| | | | - Masanori Teramura
- Department of Cardiovascular Medicine, Ichinomiya Nishi Hospital, Aichi 494-0001, Japan;
| | - Tetsuro Takase
- Department of Cardiovascular Medicine, Ichinomiya Nishi Hospital, Aichi 494-0001, Japan;
- Correspondence:
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Napolitano JD. The Physical Examination to Assess for Anemia and Hypovolemia. Med Clin North Am 2022; 106:509-518. [PMID: 35491070 DOI: 10.1016/j.mcna.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Hypovolemia develops with the loss of extracellular fluid volume or blood. Rapidly identifying hypovolemia can be lifesaving. Indicators of hypovolemia on examination include supine or postural hypotension, increase in heart rate by 30 beats per minute or severe dizziness with standing, and a decrease in central venous pressure detected on visual inspection of the jugular venous pressure or ultrasound assessment of the inferior vena cava or internal jugular veins. Other findings with utility include a dry axilla and dry oral mucosa. With chronic anemia, hemodynamic changes detectable on examination may be minimal, as the body compensates by retaining extracellular volume.
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Affiliation(s)
- Jason D Napolitano
- David Geffen School of Medicine at UCLA, 757 Westwood Plaza Suite 7501, Los Angeles, CA 90095, USA.
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7
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Moore HG, Justen MA, Kirwin DS, Burroughs PJ, Rubin LE, Grauer JN. Does dehydration prior to primary total joint arthroplasty increase risk of perioperative complications? ARTHROPLASTY 2021; 3:34. [PMID: 35236481 PMCID: PMC8796573 DOI: 10.1186/s42836-021-00090-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior studies have suggested that preoperative dehydration increases odds of perioperative complications in several areas of orthopedic surgery. This study aimed to evaluate whether preoperative hydration status is associated with the incidence of short-term complications after primary total joint arthroplasty. METHODS The 2012-2019 National Surgical Quality Improvement Program (NSQIP) database was used to explore the relationship between preoperative dehydration (ratio of preoperative BUN divided by preoperative Creatinine (BUN/Creatinine) > 20) and perioperative outcomes of total hip (THA) and total knee arthroplasty (TKA) patients. Univariate comparisons and multivariate regression analyses were conducted to identify specific complications that occurred more often in patients with preoperative dehydration. RESULTS Of 188,629 THA and 332,485 TKA patients, 46.3 and 47.0% had preoperative dehydration, respectively. After controlling for demographics and comorbidities, dehydrated THA patients were no more likely to experience a complication compared to their non-dehydrated counterparts (relative risk [RR] = 0.97, 99.7% Confidence Interval [CI]: 0.92-1.03, P = 0.138) nor increased risk of blood transfusion (RR = 1.02, CI = 0.96-1.08, P = 0.408). Similar to THA patients, dehydrated TKA patients were not more likely to have a complication after surgery (RR = 0.97, CI = 0.92-1.03, P = 0.138) and were at no greater risk of transfusion (RR = 1.02, CI = 0.96-1.07, P = 0.408). A sub-analysis covering only patients with BUN and Cr values determined within 24 h after surgery was performed and similarly found no significant increase in perioperative complications or transfusion. CONCLUSION Overall, preoperative dehydration in patients undergoing THA/TKA did not appear to increase risk of transfusion or other perioperative complications. Further research is needed to characterize the role of hydration prior to elective total joint arthroplasty.
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Affiliation(s)
| | | | | | | | - Lee E Rubin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06511, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, 47 College Street, New Haven, CT, 06511, USA.
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Ho V, Goh G, Tang XR, See KC. Underrecognition and undertreatment of thirst among hospitalized patients with restricted oral feeding and drinking. Sci Rep 2021; 11:13636. [PMID: 34211006 PMCID: PMC8249500 DOI: 10.1038/s41598-021-93048-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/21/2021] [Indexed: 11/08/2022] Open
Abstract
Thirst is distressing but overlooked by healthcare professionals. Patients experience thirst due to comorbidities, physical or cognitive limitations, and iatrogenesis. Nasogastric tube (NGT) use and nil-by-mouth(NBM) orders are common practices that can lead to thirst. However, thirst in these populations has never been formally studied. We aim to examine prevalence of recognition and treatment of thirst among NGT + NBM and NBM patients. Our descriptive study was conducted intermittently over 25 weeks, across 1.5 years, in 12 adult general medicine wards of a tertiary hospital. Cognitively intact NGT + NBM or NBM inpatients, defined as Abbreviated Mental Test score ≥ 8, were studied. One-time questionnaire was administered. Variables included: demography, co-morbidities, clinical condition, feeding route, thirst defined by thirst distress and/or intensity ≥ 3, pain, hunger and volume status. 88 NGT + NBM and NBM patients were studied. 69.3% suffered from thirst. Thirsty patients experienced significant thirst-related distress (mean score ± SD: 5.7 ± 2.5). Subjects with previous stroke and who were euvolemic tended towards thirst. 13.6% were asked about thirst by doctors or nurses. Thirst was a major source of patient distress in our study. We suggest that thirst needs to be actively identified and targeted to achieve person-centred care.
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Affiliation(s)
- Vanda Ho
- Department of Geriatric Medicine, National University Hospital, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore.
| | - Gordon Goh
- Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Xuan Rong Tang
- Yong Loo Lin School of Medicine, National University, Singapore, Singapore
| | - Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore, Singapore
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Bennet D, Khorsandian Y, Pelusi J, Mirabella A, Pirrotte P, Zenhausern F. Molecular and physical technologies for monitoring fluid and electrolyte imbalance: A focus on cancer population. Clin Transl Med 2021; 11:e461. [PMID: 34185420 PMCID: PMC8214861 DOI: 10.1002/ctm2.461] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/11/2021] [Accepted: 05/29/2021] [Indexed: 12/23/2022] Open
Abstract
Several clinical examinations have shown the essential impact of monitoring (de)hydration (fluid and electrolyte imbalance) in cancer patients. There are multiple risk factors associated with (de)hydration, including aging, excessive or lack of fluid consumption in sports, alcohol consumption, hot weather, diabetes insipidus, vomiting, diarrhea, cancer, radiation, chemotherapy, and use of diuretics. Fluid and electrolyte imbalance mainly involves alterations in the levels of sodium, potassium, calcium, and magnesium in extracellular fluids. Hyponatremia is a common condition among individuals with cancer (62% of cases), along with hypokalemia (40%), hypophosphatemia (32%), hypomagnesemia (17%), hypocalcemia (12%), and hypernatremia (1-5%). Lack of hydration and monitoring of hydration status can lead to severe complications, such as nausea/vomiting, diarrhea, fatigue, seizures, cell swelling or shrinking, kidney failure, shock, coma, and even death. This article aims to review the current (de)hydration (fluid and electrolyte imbalance) monitoring technologies focusing on cancer. First, we discuss the physiological and pathophysiological implications of fluid and electrolyte imbalance in cancer patients. Second, we explore the different molecular and physical monitoring methods used to measure fluid and electrolyte imbalance and the measurement challenges in diverse populations. Hydration status is assessed in various indices; plasma, sweat, tear, saliva, urine, body mass, interstitial fluid, and skin-integration techniques have been extensively investigated. No unified (de)hydration (fluid and electrolyte imbalance) monitoring technology exists for different populations (including sports, elderly, children, and cancer). Establishing novel methods and technologies to facilitate and unify measurements of hydration status represents an excellent opportunity to develop impactful new approaches for patient care.
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Affiliation(s)
- Devasier Bennet
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
| | - Yasaman Khorsandian
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
| | | | | | - Patrick Pirrotte
- Collaborative Center for Translational Mass SpectrometryTranslational Genomics Research InstitutePhoenixUSA
| | - Frederic Zenhausern
- Center for Applied NanoBioscience and MedicineThe University of ArizonaCollege of MedicinePhoenixUSA
- HonorHealth Research InstituteScottsdaleUSA
- Collaborative Center for Translational Mass SpectrometryTranslational Genomics Research InstitutePhoenixUSA
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Elhassan MG, Chao PW, Curiel A. The Conundrum of Volume Status Assessment: Revisiting Current and Future Tools Available for Physicians at the Bedside. Cureus 2021; 13:e15253. [PMID: 34188992 PMCID: PMC8231469 DOI: 10.7759/cureus.15253] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Assessment of patients’ volume status at the bedside is a very important clinical skill that physicians need in many clinical scenarios. Hypovolemia with hypotension and tissue under-perfusion are usually more alarming to physicians, but hypervolemia is also associated with poor outcomes, making euvolemia a crucial goal in clinical practice. Nevertheless, the assessment of volume status can be challenging, especially in the absence of a gold standard test that is reliable and easily accessible to assist with clinical decision-making. Physicians need to have a broad knowledge of the individual non-invasive clinical tools available for them at the bedside to evaluate volume status. In this review, we will discuss the strengths and limitations of the traditional tools, which include careful history taking, physical examination, and basic laboratory tests, and also include the relatively new tool of point-of-care ultrasound.
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Affiliation(s)
| | - Peter W Chao
- Internal Medicine, Saint Agnes Medical Center, Fresno, USA
| | - Argenis Curiel
- Internal Medicine, Saint Agnes Medical Center, Fresno, USA
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Levine AC, Barry MA, Gainey M, Nasrin S, Qu K, Schmid CH, Nelson EJ, Garbern SC, Monjory M, Rosen R, Alam NH. Derivation of the first clinical diagnostic models for dehydration severity in patients over five years with acute diarrhea. PLoS Negl Trop Dis 2021; 15:e0009266. [PMID: 33690646 PMCID: PMC7984611 DOI: 10.1371/journal.pntd.0009266] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/22/2021] [Accepted: 02/23/2021] [Indexed: 12/31/2022] Open
Abstract
Diarrheal diseases lead to an estimated 1.3 million deaths each year, with the majority of those deaths occurring in patients over five years of age. As the severity of diarrheal disease can vary widely, accurately assessing dehydration status remains the most critical step in acute diarrhea management. The objective of this study is to empirically derive clinical diagnostic models for assessing dehydration severity in patients over five years with acute diarrhea in low resource settings. We enrolled a random sample of patients over five years with acute diarrhea presenting to the icddr,b Dhaka Hospital. Two blinded nurses independently assessed patients for symptoms/signs of dehydration on arrival. Afterward, consecutive weights were obtained to determine the percent weight change with rehydration, our criterion standard for dehydration severity. Full and simplified ordinal logistic regression models were derived to predict the outcome of none (<3%), some (3-9%), or severe (>9%) dehydration. The reliability and accuracy of each model were assessed. Bootstrapping was used to correct for over-optimism and compare each model's performance to the current World Health Organization (WHO) algorithm. 2,172 patients were enrolled, of which 2,139 (98.5%) had complete data for analysis. The Inter-Class Correlation Coefficient (reliability) was 0.90 (95% CI = 0.87, 0.91) for the full model and 0.82 (95% CI = 0.77, 0.86) for the simplified model. The area under the Receiver-Operator Characteristic curve (accuracy) for severe dehydration was 0.79 (95% CI: 0.76-0.82) for the full model and 0.73 (95% CI: 0.70, 0.76) for the simplified model. The accuracy for both the full and simplified models were significantly better than the WHO algorithm (p<0.001). This is the first study to empirically derive clinical diagnostic models for dehydration severity in patients over five years. Once prospectively validated, the models may improve management of patients with acute diarrhea in low resource settings.
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Affiliation(s)
- Adam C. Levine
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Meagan A. Barry
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Monique Gainey
- Rhode Island Hospital, Providence, Rhode Island, United States of America
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kexin Qu
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Christopher H. Schmid
- Department of Biostatistics, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Eric J. Nelson
- Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
| | - Stephanie C. Garbern
- Department of Emergency Medicine, Warren Alpert Medical School, Brown University, Providence, Rhode Island, United States of America
| | - Mahmuda Monjory
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rochelle Rosen
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, Rhode Island, United States of America
| | - Nur H. Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Subcutaneous Versus Intravenous Rehydration in Hospitalized Older Adults: A Meta-Analysis. JOURNAL OF INFUSION NURSING 2020; 43:283-291. [PMID: 32881815 DOI: 10.1097/nan.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Subcutaneous rehydration is an optional infusion route in hospitalized older adults. This meta-analysis sought to compare the effectiveness of subcutaneous versus intravenous (IV) fluid administration to reverse mild-to-moderate dehydration in hospitalized older adults. A literature search was performed. No restrictions were imposed regarding language. Three randomized clinical trials conducted with patients 60 years of age or older treated with subcutaneous or IV rehydration were included, with a total sample size of 197 patients. Controlled quasi-randomized and crossover trials were excluded. The primary end point was reversal of dehydration. Secondary end points were patient satisfaction and frequency of adverse events (eg, cellulitis, edema, phlebitis, erythema, hyponatremia, and pain). Both treatments were effective in rehydrating the patients within 48 hours, with no statistically significant difference between the groups. Subcutaneous fluid administration effectively reversed dehydration while protecting against phlebitis. Since the quality of evidence was considerably low, further multicenter randomized clinical trials of efficient methodological quality should be conducted to consolidate the body of evidence.
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14
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Preoperative Dehydration does not Increase the Risk of Complications Following Elective Lumbar Surgery. Spine (Phila Pa 1976) 2019; 44:E1336-E1341. [PMID: 31689256 DOI: 10.1097/brs.0000000000003149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to evaluate the effect of preoperative dehydration on hospital length of stay (LOS), rates of 30-day postoperative complications, related reoperations, and readmissions. SUMMARY OF BACKGROUND DATA Preoperative dehydration has long been associated with postoperative infection, deep vein thrombosis (DVT), acute renal failure, and an increased hospital LOS. To our knowledge, the effect of preoperative dehydration on complication rates for patients undergoing elective lumbar spine surgery has not been well described. METHODS An analysis of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data from 2006 to 2013 was performed. Patients undergoing elective lumbar procedures were identified and exclusion criteria eliminated patients who underwent any emergency procedures, infections, tumor cases, or revision surgeries. Patient dehydration was defined as preoperative blood urea nitrogen/creatinine (BUN/Cr) ratio greater than 20. RESULTS Patients (4698; 34.5%) with preoperative dehydration based on BUN/Cr ratio were identified. Univariate analysis was suggestive of an association between preoperative dehydration and an increased risk of DVT (1.1% compared with 0.6%; P = 0.002), urinary tract infection (2.5% compared with 1.6%; P < 0.001), and need for transfusion postoperatively (17.6% compared with 14.4%; P < 0.001). However, on the basis of multivariate regression, no significant association between dehydration and increased odds of aforementioned outcomes was identified. CONCLUSION Preoperative dehydration does not appear to negatively affect perioperative outcomes or readmission in patients undergoing elective lumbar spine surgery. LEVEL OF EVIDENCE 3.
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Bashyam A, Frangieh CJ, Li M, Cima MJ. Dehydration assessment via a portable, single sided magnetic resonance sensor. Magn Reson Med 2019; 83:1390-1404. [PMID: 31631380 DOI: 10.1002/mrm.28004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Undiagnosed dehydration compromises health outcomes across many populations. Existing dehydration diagnostics require invasive bodily fluid sampling or are easily confounded by fluid and electrolyte intake, environment, and physical activity limiting widespread adoption. We present a portable MR sensor designed to measure intramuscular fluid shifts to identify volume depletion. METHODS Fluid loss is induced via a mouse model of thermal dehydration (37°C; 15-20% relative humidity). We demonstrate quantification of fluid loss induced by hyperosmotic dehydration with multicomponent T2 relaxometry using both a benchtop NMR system and MRI localized to skeletal muscle tissue. We then describe a miniaturized (~1000 cm3 ) portable (~4 kg) MR sensor (0.28 T) designed to identify dehydration-induced fluid loss. T2 relaxometry measurements were performed using a Carr-Purcell-Meiboom-Gill pulse sequence in ~4 min. RESULTS T2 values from the portable MR sensor exhibited strong (R2 = 0.996) agreement with benchtop NMR spectrometer. Thermal dehydration induced weight loss of 4 to 11% over 5 to 10 h. Fluid loss induced by thermal dehydration was accurately identified via whole-animal NMR and skeletal muscle. The portable MR sensor accurately identified dehydration via multicomponent T2 relaxometry. CONCLUSION Performing multicomponent T2 relaxometry localized to the skeletal muscle with a miniaturized MR sensor provides a noninvasive, physiologically relevant measure of dehydration induced fluid loss in a mouse model. This approach offers sensor portability, reduced system complexity, fully automated operation, and low cost compared with MRI. This approach may serve as a versatile and portable point of care technique for dehydration monitoring.
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Affiliation(s)
- Ashvin Bashyam
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Chris J Frangieh
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Matthew Li
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Harvard-MIT Program in Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Michael J Cima
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
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De Freitas G, Gudur A, Vela-Ortiz M, Jodelka J, Livert D, Krishnamurthy M. Where there is sodium there may be sepsis. J Community Hosp Intern Med Perspect 2019; 9:296-299. [PMID: 31528275 PMCID: PMC6735289 DOI: 10.1080/20009666.2019.1634407] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/17/2019] [Indexed: 11/14/2022] Open
Abstract
Hypernatremia affects up to 9% of critically ill patients upon hospital admission, especially in elderly patients with thirst impairment. However, hypernatremia is not entirely explained by fluid imbalance. Recent studies suggest that sodium is an important enhancer of the immune system, raising the question of whether inflammatory states such as sepsis may contribute to hypernatremia. Although sepsis patients with hypernatremia face a greater mortality rate, there is a lack of studies examining a potential association between hypernatremia and sepsis. Motivated by the frequent concurrence of hypernatremia and sepsis observed at an eastern Pennsylvanian community hospital, the current study was conducted to evaluate whether hypernatremia on admission may serve as a potential surrogate marker for sepsis. The medical records of 153 patients with hypernatremia on admission (serum sodium > 145mEq/L) were retrospectively analyzed. The mean age of patients was 81.1. Sepsis was observed in 77.1% of patients, of which 86.2% had dementia. This study demonstrated a positive correlation between hypernatremia on admission and the presence of sepsis. We suggest that the existence of hypernatremia should prompt clinicians to further investigate for sources of infection, especially in the elderly and patients with dementia.
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Affiliation(s)
| | - Anuragh Gudur
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Jacek Jodelka
- St. Luke's University Hospital, Fountain Hill, PA, USA
| | - David Livert
- Internal Medicine, Easton Hospital, Easton, PA, USA.,Drexel University College of Medicine, Philadelphia, PA, USA
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Sato K, Okajima M, Taniguchi T. Association of Persistent Intense Thirst With Delirium Among Critically Ill Patients: A Cross-sectional Study. J Pain Symptom Manage 2019; 57:1114-1120. [PMID: 30831240 DOI: 10.1016/j.jpainsymman.2019.02.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/11/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
CONTEXT Thirst is a prevalent distressing symptom often reported by patients in the intensive care unit (ICU). Little is known about the association of thirst with delirium. OBJECTIVE We aimed to investigate the relationship between thirst and delirium. METHODS This retrospective cross-sectional study enrolled 401 patients who were evaluated for thirst intensity in the ICU between March 2017 and October 2017. We assessed thirst intensity on a scale of 0-10 (with 10 being the worst) and defined intense thirst as a score ≥8. If intense thirst persisted for more than 24 hours, we defined it as persistent intense thirst. Delirium was screened using the Intensive Care Delirium Screening Checklist. Propensity score matching and inverse probability of treatment weighting analyses were performed. RESULTS Of 401 patients, 66 (16.5%) had intense thirst sensation for more than 24 hours. After matching, patients with persistent intense thirst showed an increased risk for delirium compared with those without persistent intense thirst (odds ratio, 4.95; 95% confidence interval, 2.58-9.48; P < 0.001). Propensity score weighted logistic regression analysis also indicated that persistent intense thirst was significantly associated with delirium (odds ratio, 5.74; 95% confidence interval, 2.53-12.99; P < 0.001). CONCLUSION Intense thirst persisting for more than 24 hours was associated with increased risk for delirium.
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Affiliation(s)
- Koji Sato
- Intensive Care Unit, Kanazawa University Hospital, Kanazawa, Japan.
| | - Masaki Okajima
- Intensive Care Unit, Kanazawa University Hospital, Kanazawa, Japan
| | - Takumi Taniguchi
- Intensive Care Unit, Kanazawa University Hospital, Kanazawa, Japan; Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Cortés-Vicente E, Guisado-Alonso D, Delgado-Mederos R, Camps-Renom P, Prats-Sánchez L, Martínez-Domeño A, Martí-Fàbregas J. Frequency, Risk Factors, and Prognosis of Dehydration in Acute Stroke. Front Neurol 2019; 10:305. [PMID: 30984104 PMCID: PMC6450136 DOI: 10.3389/fneur.2019.00305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/11/2019] [Indexed: 12/28/2022] Open
Abstract
Objective: To determine the frequency, risk factors, and impact on the outcome of dehydration after stroke. Methods: In this cross-sectional observational study, we included prospectively and consecutively patients with ischemic and hemorrhagic stroke. The serum Urea/Creatinine ratio (U/C) was calculated at admission and 3 days after the stroke. Dehydration was defined as U/C>80. Patients were treated in accordance with the standard local hydration protocol. Demographic and clinical data were collected. Neurological severity was evaluated at admission according to the NIHSS score; functional outcome was assessed with the modified Rankin scale score (mRS) at discharge and 3 months after the stroke. Unfavorable outcome was defined as mRS > 2. Results: We evaluated 203 patients; 78.8% presented an ischemic stroke and 21.2% a hemorrhagic stroke. The mean age was 73.4 years ±12.9; 51.7% were men. Dehydration was detected in 18 patients (8.9%), nine patients at admission (4.5%), and nine patients (4.5%) at 3 days after the stroke. Female sex (OR 3.62, 95%CI 1.13-11.58, p = 0.03) and older age (OR 1.05, 95%CI 1-1.11, p = 0.048) were associated with a higher risk of dehydration. Dehydration was significantly associated with an unfavorable outcome at discharge (OR 5.16, 95%CI 1.45-18.25, p = 0.011), but the association was not significant at 3 months (OR 2.95, 95%CI 0.83-10.48, p = 0.095). Conclusion: Dehydration is a treatable risk factor of a poor functional outcome after stroke that is present in 9% of patients. Females and elders present a higher risk of dehydration.
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Affiliation(s)
- Elena Cortés-Vicente
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Guisado-Alonso
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raquel Delgado-Mederos
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pol Camps-Renom
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Prats-Sánchez
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alejandro Martínez-Domeño
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Martí-Fàbregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
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Bunn DK, Hooper L. Signs and Symptoms of Low-Intake Dehydration Do Not Work in Older Care Home Residents-DRIE Diagnostic Accuracy Study. J Am Med Dir Assoc 2019; 20:963-970. [PMID: 30872081 DOI: 10.1016/j.jamda.2019.01.122] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/04/2019] [Accepted: 01/05/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To assess the diagnostic accuracy of commonly used signs and symptoms of low-intake dehydration in older care home residents. DESIGN Prospective diagnostic accuracy study. SETTING 56 care homes offering residential, nursing, and/or dementia care to older adults in Norfolk and Suffolk, United Kingdom. PARTICIPANTS 188 consecutively recruited care home residents aged ≥65 years, without cardiac or renal failure and not receiving palliative care. Overall, 66% were female, the mean age was 85.7 years (standard deviation 7.8), and the median Mini-Mental State Examination MMSE score was 23 (interquartile range 18-26). INDEX TESTS Over 2 hours, participants underwent double-blind assessment of 49 signs and symptoms of dehydration and measurement of serum osmolality from a venous blood sample. Signs and symptoms included skin turgor; mouth, skin, and axillary dryness; capillary refill; sunken eyes; blood pressure on resting and after standing; body temperature; pulse rate; and self-reported feelings of thirst and well-being. REFERENCE STANDARD Serum osmolality, with current dehydration defined as >300 mOsm/kg, and impending dehydration ≥295 mOsm/kg. OUTCOME MEASURES For dichotomous tests, we aimed for sensitivity and specificity >70%, and for continuous tests, an area under the curve in receiver operating characteristic plots of >0.7. RESULTS Although 20% of residents had current low-intake dehydration and a further 28% impending dehydration, none of the commonly used clinical signs and symptoms usefully discriminated between participants with or without low-intake dehydration at either cut-off. CONCLUSIONS/IMPLICATIONS This study consolidates evidence that commonly used signs and symptoms of dehydration lack even basic levels of diagnostic accuracy in older adults, implying that many who are dehydrated are not being identified, thus compromising their health and well-being. We suggest that these tests be withdrawn from practice and replaced with a 2-stage screening process that includes serum osmolarity, calculated from sodium, potassium, urea, and glucose levels (assessed routinely using the Khajuria and Krahn equation), followed by serum osmolality measurement for those identified as high risk (calculated serum osmolarity >295 mmol/L).
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Affiliation(s)
- Diane K Bunn
- School of Health Sciences, Norwich Research Park, University of East Anglia, Norwich, Norfolk, England, United Kingdom.
| | - Lee Hooper
- Norwich Medical School, Norwich Research Park, University of East Anglia, Norwich, Norfolk, England, United Kingdom
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20
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Asim M, Alkadi MM, Asim H, Ghaffar A. Dehydration and volume depletion: How to handle the misconceptions. World J Nephrol 2019; 8:23-32. [PMID: 30705869 PMCID: PMC6354080 DOI: 10.5527/wjn.v8.i1.23] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 11/02/2018] [Accepted: 01/04/2019] [Indexed: 02/06/2023] Open
Abstract
Dehydration and volume depletion describe two distinct body fluid deficit disorders with differing pathophysiology, clinical manifestations and treatment approaches. However, the two are often confused or equated with each other. Here, we address a number of commonly encountered misconceptions about body-fluid deficit disorders, analyse their origins and propose approaches to overcome them.
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Affiliation(s)
- Muhammad Asim
- Hamad General Hospital, Hamad Medical Corporation and Weill Cornell Medicine-Qatar, Doha 3050, Qatar
| | - Mohamad M Alkadi
- Hamad General Hospital, Hamad Medical Corporation and Weill Cornell Medicine-Qatar, Doha 3050, Qatar
| | - Hania Asim
- Birmingham City Hospital, Dudley Road, Birmingham B18 7QH, United Kingdom
| | - Adil Ghaffar
- Saint Vincent Hospital, Worcester, MA 01608, United States
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21
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Betomvuko P, de Saint-Hubert M, Schoevaerdts D, Jamart J, Devuyst O, Swine C. Early diagnosis of dehydration in hospitalized geriatric patients using clinical and laboratory criteria. Eur Geriatr Med 2018; 9:589-595. [DOI: 10.1007/s41999-018-0100-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 08/21/2018] [Indexed: 12/28/2022]
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22
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Johnson P, Hahn RG. Signs of Dehydration in Nursing Home Residents. J Am Med Dir Assoc 2018; 19:1124-1128. [PMID: 30228079 DOI: 10.1016/j.jamda.2018.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/25/2018] [Accepted: 07/28/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Although dehydration can affect mental and physical health, there is no clear, consistent, and reproducible diagnostic tool for this condition in older people. We applied multiple methods to detect dehydration with the aim of assessing the value of using urine analysis for this purpose. DESIGN Nonrandomized cohort study. SETTING AND PARTICIPANTS Sixty nursing home residents, aged 64-103 (mean 84) years. METHODS Sampling of morning urine, blood analyses, and clinical examination. A previously validated algorithm summarized the urine specific gravity, osmolality, creatinine, and color to a Fluid Retention Index (FRI). RESULTS The cut-off for renal fluid conservation consistent with dehydration (FRI ≥ 4.0) was reached by 51% of the cohort. No statistically significant linear correlation was found between FRI and serum osmolality (mean 307.5 mOsmol/kg) or plasma sodium (mean 139 mmol/L), but the subjects reported less thirst with increasing FRI scores (linear correlation r = -0.35; P < .03). Clinical examinations of mucous membranes and tongue furrows did not correlate with other markers of dehydration. Subjects with sunken eyes had higher C-reactive protein (P < .02) and lower albumin (P < .002) concentrations in plasma than the others, while impaired skin turgor only correlated with age (P < .04). CONCLUSIONS/IMPLICATIONS Renal fluid conservation consistent with dehydration was found in half of the nursing home residents, which could partially be accounted for by decreased thirst. Clinical examinations probably reflected the physical status and age more than dehydration. The lack of correlation between the serum osmolality and the FRI, both of which are purported to be gold standards for dehydration, raises questions about whether a gold standard exists.
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Affiliation(s)
- Peter Johnson
- Department of Geriatrics and Internal Medicine, Södertälje Hospital, Södertälje, Sweden
| | - Robert G Hahn
- Department of Research, Södertälje Hospital, Södertälje, Sweden; Karolinska Institutet at Danderyds Hospital (KIDS), Stockholm, Sweden.
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23
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Kim MS, Shin DS, Kim S. One-year mortality among newly admitted older patients in a long-term care hospital in South Korea. Australas J Ageing 2018; 37:232-235. [PMID: 30028560 DOI: 10.1111/ajag.12567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Older Korean people's admission to long-term care (LTC) hospitals is increasing. This study aimed to investigate one-year mortality and related factors among older patients admitted to a LTC hospital. METHODS Medical records of 330 patients admitted to a LTC hospital in 2014 were reviewed. Factors related to death were identified using the Cox proportional hazards model. RESULTS About 35% of the patients died within a year, and their average length of survival was 42.3 (SD = 68.4) days. Predictors of mortality within one year were as follows: cancer (hazard ratio (HR) = 3.04); aged 85 and older (HR = 2.61); dependency: K-ADL ≥ 21 (HR = 2.14); male sex (HR = 1.95); respiratory disease (HR = 1.68); cognitive function (HR = 1.65); and abnormal serum sodium level (HR = 1.65). CONCLUSION At admission, proper assessment and planning for older patients at risk are beneficial to minimise negative consequences. The roles of LTC hospitals need further discussion.
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Affiliation(s)
- Mi Sook Kim
- Department of Nursing, Kaya University, Gimhae, South Korea
| | - Dong-Soo Shin
- Division of Nursing, Research Institute of Nursing Science, Hallym University, Chuncheon, South Korea
| | - SookNyeo Kim
- Division of Nursing, Research Institute of Nursing Science, Hallym University, Chuncheon, South Korea
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Could patient-controlled thirst-driven fluid administration lead to more rapid rehydration than clinician-directed fluid management? An early feasibility study. Br J Anaesth 2018; 120:284-290. [DOI: 10.1016/j.bja.2017.11.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 09/06/2017] [Accepted: 09/13/2017] [Indexed: 11/20/2022] Open
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Elgot A, El Hiba O, Belkouch M, Gamrani H. The underlying physiological basis of the desert rodent Meriones shawi's survival to prolonged water deprivation: Central vasopressin regulation on peripheral kidney water channels AQPs-2. Acta Histochem 2018; 120:65-72. [PMID: 29217107 DOI: 10.1016/j.acthis.2017.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/15/2017] [Accepted: 11/17/2017] [Indexed: 12/19/2022]
Abstract
Meriones shawi (M. shawi) is a particular semi-desert rodent known by its resistance to long periods of thirst. The aim of the present investigation is to clarify the underlying mechanisms allowing M. shawi to resist to hard conditions of dehydration. For this reason we used two different approaches: i) a morphometric study, which consists in measuring the effect of dehydration on body and kidneys weights as well as the report kidney weight/body weight, ii) By immunohistochemistry, we proceed to study the effect of dehydration on the immunoreactivity of central vasopressin (AVP) and the kidney aquaporin-2 (AQP-2) which is a channel protein that allows water to permeate across cell membranes. Our results showed both a body mass decrease accompanied by a remarkable kidneys hypertrophy. The immunohistochemical study showed a significant increase of AQP-2 immunoreactivity in the medullar part of Meriones kidneys allowing probably to Meriones a great ability to water retention. Consistently, we demonstrate that the increased AQP-2 expression occurred together with an increase in vasopressin (AVP) expression in both hypothalamic supraoptic (SON) and paraventricular nucleus (PVN), which are a major hub in the osmotic control circuitry. These various changes seen either in body weight and kidneys or at the cellular level might be the basis of peripheral control of body water homeostasis, providing to M. shawia strong resistance against chronic dehydration.
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Hughes F, Mythen M, Montgomery H. The sensitivity of the human thirst response to changes in plasma osmolality: a systematic review. Perioper Med (Lond) 2018; 7:1. [PMID: 29344350 PMCID: PMC5763530 DOI: 10.1186/s13741-017-0081-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 12/21/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Dehydration is highly prevalent and is associated with adverse cardiovascular and renal events. Clinical assessment of dehydration lacks sensitivity. Perhaps a patient's thirst can provide an accurate guide to fluid therapy. This systematic review examines the sensitivity of thirst in responding to changes in plasma osmolality in participants of any age with no condition directly effecting their sense of thirst. METHODS Medline and EMBASE were searched up to June 2017. Inclusion criteria were all studies reporting the plasma osmolality threshold for the sensation of thirst. RESULTS A total of 12 trials were included that assessed thirst intensity on a visual analogue scale, as a function of plasma osmolality (pOsm), and employed linear regression to define the thirst threshold. This included 167 participants, both healthy controls and those with a range of pathologies, with a mean age of 41 (20-78) years.The value ±95% CI for the pOsm threshold for thirst sensation was found to be 285.23 ± 1.29 mOsm/kg. Above this threshold, thirst intensity as a function of pOsm had a mean ± SEM slope of 0.54 ± 0.07 cm/mOsm/kg. The mean ± 95% CI vasopressin release threshold was very similar to that of thirst, being 284.3 ± 0.71 mOsm/kg.Heterogeneity across studies can be accounted for by subtle variation in experimental protocol and data handling. CONCLUSION The thresholds for thirst activation and vasopressin release lie in the middle of the normal range of plasma osmolality. Thirst increases linearly as pOsm rises. Thus, osmotically balanced fluid administered as per a patient's sensation of thirst should result in a plasma osmolality within the normal range. This work received no funding.
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Affiliation(s)
- Fintan Hughes
- Institute for Sport, Exercise and Health, University College London, 170 Tottenham Court Road, London, W1T 7HA UK
| | - Monty Mythen
- Institute for Sport, Exercise and Health, University College London, 170 Tottenham Court Road, London, W1T 7HA UK
| | - Hugh Montgomery
- Institute for Sport, Exercise and Health, University College London, 170 Tottenham Court Road, London, W1T 7HA UK
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27
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Babar F, Singh G, Noor M, Sabath B. Retrospective analysis of inferior vena cava collapsibility with point of care ultrasound and urine sodium and FENa in patients with early stage acute kidney injury. J Community Hosp Intern Med Perspect 2017; 7:296-299. [PMID: 29147470 PMCID: PMC5676799 DOI: 10.1080/20009666.2017.1378048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/01/2017] [Indexed: 01/31/2023] Open
Abstract
Early stage acute kidney injury (AKI) is an independent risk factor for an increase in mortality. Accurate assessment of volume status is a major challenge during the early stages of acute renal injury. Determining volume status based on the history and physical exam lacks accuracy. Urine sodium and free excretion of sodium (FENa) provide objective evidence of intravascular volume status when interpreted carefully and is helpful to delineate prerenal from intrinsic renal failure. In recent years point of care ultrasound has been used to assess volume status. Our team conducted a retrospective chart review to assess the association of inferior vena cava collapsibility by point of care ultrasound (POCUS) and urine electrolytes (urine sodium, fractional excretion of sodium) during early stage AKI (Stage 1–2 of KDIGO guidelines). We reviewed 150 cases based on the provisional diagnosis. 36 patients met the criteria for further review. Using bivariate analysis, we found a strong association between >50% IVC collapsibility with FENa < 0.4% with an odds ratio 5.3 (CI 1.1–24.5, p = 0.04), and urine sodium <20 meq/dl with an odds ratio of 6.7 (Cl 1.5–30, p = 0.02). Subsequently, multivariate analysis and Spearman correlation showed an inverse relation between IVC collapsibility and fractional excretion of sodium FENa (β = −0.4, p = 0.001) and (r = −0.44, p = 0.01). These findings suggest the role of POCUS and urinary markers in determining the intravascular volume status in AKI. POCUS is also valuable to assess volume status in cases of renal failure where urine studies are difficult to interpret.
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Affiliation(s)
- Faizan Babar
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Gurkeerat Singh
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Mustafa Noor
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
| | - Bruce Sabath
- Department of Internal Medicine, Greater Baltimore Medical Center, MD, USA
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Fehlberg EA, Lucero RJ, Weaver MT, McDaniel AM, Chandler AM, Richey PA, Mion LC, Shorr RI. Associations between hyponatraemia, volume depletion and the risk of falls in US hospitalised patients: a case-control study. BMJ Open 2017; 7:e017045. [PMID: 28790043 PMCID: PMC5724091 DOI: 10.1136/bmjopen-2017-017045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE We aimed to determine if abnormal laboratory values which may indicate volume depletion are associated with increased odds of experiencing a hospital-acquired fall. DESIGN Matched case-control study. SETTING Four hospitals located in the Southeast USA. PARTICIPANTS Data from 699 adult fallers and 1189 matched controls (non-fallers) were collected via chart review from 2005 to 2010. Controls were matched to cases by nursing unit, time of fall and length of stay. OUTCOME MEASURES The primary exposures included serum sodium, blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio and haematocrit. Conditional logistic regression with m:n matching was used to determine adjusted and unadjusted ORs. RESULTS Serum sodium levels were strongly associated with falls. In models controlling for demographic and other fall risk factors, patients with serum sodium levels of 125 mEq/L or less were associated with increased odds of experiencing a fall as compared with those with serum sodium levels of greater than 134 mEq/L (adjusted OR (aOR)=5.08, 95% CI 1.43 to 18.08). Conversely, elevated BUN, creatinine and elevated BUN/creatinine ratios were not associated with increased odds of experiencing a fall (aOR=0.64, 95% CI 0.49 to 0.84; aOR=0.70, 95% CI 0.54 to 0.92 and aOR=0.77, 95% CI 0.58 to 1.04, respectively.) CONCLUSIONS: Laboratory indices that may indicate volume depletion appear to be unrelated to falls. However, hyponatraemia does appear to be a risk factor for falls, and those with serum sodium levels below 126 mEq/L are at especially high risk. It may be that other deficits associated with hyponatraemia, like altered mental status, are associated with risk of experiencing a hospital-acquired fall. These results indicate that abnormal laboratory values, like low sodium, can be useful for identifying hospitalised patients at risk of falling. Therefore, further investigation into abnormal laboratory values as predictors of hospital-acquired falls is warranted.
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Affiliation(s)
- Elizabeth A Fehlberg
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville, Florida, USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, USA
- Division of Research on Healthcare Value, Equity, and the Lifespan, RTI International, Research Triangle Park, NC, USA
| | - Robert J Lucero
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville, Florida, USA
- Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, USA
- Center for Innovation on Disability and Rehabilitation Research (CINDRR), Malcom Randall VAMC, Gainesville, Florida, USA
| | - Michael T Weaver
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | - Anna M McDaniel
- Departments of Biobehavioral Nursing and Family, Community, and Health System Science, University of Florida College of Nursing, Gainesville, Florida, USA
| | | | - Phyllis A Richey
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lorraine C Mion
- Center of Excellence in Critical and Complex Care, The Ohio State University College of Nursing, Columbus, Ohio, USA
| | - Ronald I Shorr
- Clinical and Translational Science Institute, University of Florida, Gainesville, Florida, USA
- Geriatric Research Education and Clinical Centers (GRECC), Malcom Randall VAMC, Gainesville, Florida, USA
- Department of Epidemiology, University of Florida, Gainesville, Florida, USA
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Labuschagne GS, Morris RW. The effect of oral intake during the immediate pre-colonoscopy time period on volume depletion in patients who receive sodium picosulfate. Anaesth Intensive Care 2017; 45:485-489. [PMID: 28673219 DOI: 10.1177/0310057x1704500412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sodium picosulfate, used in combination with magnesium oxide and citric acid for bowel cleansing, can result in dehydration. We investigated whether enhanced carbohydrate fluid intake pre-colonoscopy could mitigate this effect. We enrolled 398 elective colonoscopy patients in a prospective, controlled, single-blinded study. The control group (n=194) fasted routinely (minimum seven hours) whilst the treatment group (n=197) drank 1,200 ml carbohydrate solution leading up to admission (up until two hours pre-colonoscopy). On admission a patient survey was completed, and urine specific gravity obtained. Supine blood pressure and pulse rate were measured, and repeated within three minutes of standing. The carbohydrate group had reduced symptoms and signs of dehydration, including thirst (34% versus 65%, P <0.001), dry mouth (45% versus 59%, P=0.008), dizziness (10% versus 20%, P=0.010), lower mean urine specific gravity (1.007 versus 1.017, P <0.001), lower incidence of orthostatic hypotension (2.6% versus 11%, P <0.001), and lower mean erect pulse rate (78 versus 81 /minute, P=0.047). The postural change in systolic blood pressure was less in the treatment group (mean -0.4 mmHg, median -1 mmHg [interquartile range, IQR -7 to 7]) than in the control group (mean -4.1 mmHg, median -1 mmHg [IQR -12 to 3], P=0.028). These findings indicate that hydration with carbohydrate solution in patients taking sodium picosulfate has clinical benefit.
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Affiliation(s)
- G S Labuschagne
- Visiting Medical Officer, Department of Anaesthesia, St George Hospital, Sydney, New South Wales
| | - R W Morris
- Head of Department, Department of Anaesthesia, St George Hospital and Clinical Associate Professor, University of New South Wales, Sydney, New South Wales
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Bak A, Tsiami A, Greene C. Methods of Assessment of Hydration Status and their Usefulness in Detecting Dehydration in the Elderly. CURRENT RESEARCH IN NUTRITION AND FOOD SCIENCE 2017. [DOI: 10.12944/crnfsj.5.2.01] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Assessment of hydration status is complex and difficult to achieve. Few assessment methods have been validated to accurately measure the fluid compartments in the body, but they have little application in practice. Different techniques have been developed to determine hydration status for the use in clinical settings, but their diagnostic accuracy remains questionable. Since many experts argue that there is no 'gold-standard' technique and one can never be achieved, this paper describes both, the benefits and limitations of the available methods and their usability in assessing hydration status of the elderly.
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Affiliation(s)
- Aggie Bak
- Richard Wells Centre, College of Nursing, Midwifery and Healthcare, University of West London, London
| | - Amalia Tsiami
- London Geller College of Hospitality and Tourism University of West London, London
| | - Carolynn Greene
- Richard Wells Centre, College of Nursing, Midwifery and Healthcare, University of West London, London
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Nwosu AC, Mayland CR, Mason S, Cox TF, Varro A, Ellershaw J. The Association of Hydration Status with Physical Signs, Symptoms and Survival in Advanced Cancer-The Use of Bioelectrical Impedance Vector Analysis (BIVA) Technology to Evaluate Fluid Volume in Palliative Care: An Observational Study. PLoS One 2016; 11:e0163114. [PMID: 27673684 PMCID: PMC5038956 DOI: 10.1371/journal.pone.0163114] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 09/04/2016] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Hydration in advanced cancer is a controversial area; however, current hydration assessments methods are poorly developed. Bioelectrical impedance vector analysis (BIVA) is an accurate hydration tool; however its application in advanced cancer has not been explored. This study used BIVA to evaluate hydration status in advanced cancer to examine the association of fluid status with symptoms, physical signs, renal biochemical measures and survival. MATERIALS AND METHODS An observational study of 90 adults with advanced cancer receiving care in a UK specialist palliative care inpatient unit was conducted. Hydration status was assessed using BIVA in addition to assessments of symptoms, physical signs, performance status, renal biochemical measures, oral fluid intake and medications. The association of clinical variables with hydration was evaluated using regression analysis. A survival analysis was conducted to examine the influence of hydration status and renal failure. RESULTS The hydration status of participants was normal in 43 (47.8%), 'more hydrated' in 37 (41.1%) and 'less hydrated' in 10 (11.1%). Lower hydration was associated with increased symptom intensity (Beta = -0.29, p = 0.04) and higher scores for physical signs associated with dehydration (Beta = 10.94, p = 0.02). Higher hydration was associated with oedema (Beta = 2.55, p<0.001). Median survival was statistically significantly shorter in 'less hydrated' patients (44 vs. 68 days; p = 0.049) and in pre-renal failure (44 vs. 100 days; p = 0.003). CONCLUSIONS In advanced cancer, hydration status was associated with clinical signs and symptoms. Hydration status and pre-renal failure were independent predictors of survival. Further studies can establish the utility of BIVA as a standardised hydration assessment tool and explore its potential research application, in order to inform the clinical management of fluid balance in patients with advanced cancer.
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Affiliation(s)
- Amara Callistus Nwosu
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
| | - Catriona R. Mayland
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
| | - Stephen Mason
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
| | - Trevor F. Cox
- Liverpool Cancer Trials Unit, University of Liverpool, Liverpool, United Kingdom
| | - Andrea Varro
- School of Physiological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - John Ellershaw
- Marie Curie Palliative Care Institute Liverpool (MCPCIL), University of Liverpool, Liverpool, United Kingdom
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Marx G, Schindler AW, Mosch C, Albers J, Bauer M, Gnass I, Hobohm C, Janssens U, Kluge S, Kranke P, Maurer T, Merz W, Neugebauer E, Quintel M, Senninger N, Trampisch HJ, Waydhas C, Wildenauer R, Zacharowski K, Eikermann M. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33:488-521. [PMID: 27043493 PMCID: PMC4890839 DOI: 10.1097/eja.0000000000000447] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Gernot Marx
- From the Department of Cardiothoracic and Vascular Surgery, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz (JA); Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena (MB); Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne (ME); Institute of Nursing Science and Practice, Paracelsus Private Medical University, Salzburg, Austria (IG); Department of Internal Medicine, Neurology and Dermatology, Leipzig University Hospital, Leibzig (CH); Department of Cardiology, St Antonius Hospital, Eschweiler (UJ); Centre for Intensive Care Medicine, Universitätsklinikum, Hamburg-Eppendorf (SK); Department of Anaesthesia and Critical Care, University Hospital of Würzburg, Würzburg (PK); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (GM); Urological Unit and Outpatient Clinic, University Hospital rechts der Isar, Munich (TM); Department of Obstetrics and Gynaecology, Bonn University Hospital, Bonn (WM); Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Cologne (CM, EN); Department of Anaesthesiology, University Medical Centre Göttingen, Göttingen (MQ); Department of Intensive and Intermediate Care Medicine, University Hospital of RWTH Aachen, Aachen (AWS); Department of General and Visceral Surgery, Münster University Hospital, Münster (NS); Department of Health Informatics, Biometry and Epidemiology, Ruhr-Universität Bochum, Bochum (HJT); Department of Trauma Surgery, Essen University Hospital, Essen (CW); Department of General Surgery, University Hospital of Würzburg, Würzburg (RW); and Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany (KZ)
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Maurer C, Wagner JY, Schmid RM, Saugel B. Assessment of volume status and fluid responsiveness in the emergency department: a systematic approach. Med Klin Intensivmed Notfmed 2015; 112:326-333. [PMID: 26676240 DOI: 10.1007/s00063-015-0124-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/13/2015] [Accepted: 10/29/2015] [Indexed: 01/10/2023]
Abstract
When treating acutely ill patients in the emergency department (ED), the successful management of a variety of medical conditions, such as sepsis, acute kidney injury, and pancreatitis, is highly dependent on the correct assessment and optimization of a patient's intravascular volume status. Therefore, it is crucial that the ED physician knows and uses available means to assess intravascular volume status to adequately guide fluid therapy. This review focuses on techniques for volume status assessment that are available in the ED including basic clinical and laboratory findings, apparatus-based tests such as sonography and chest x-ray, and functional tests to evaluate fluid responsiveness. Furthermore, we provide an outlook on promising innovative, noninvasive technologies that might be used for advanced hemodynamic monitoring in the ED.
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Affiliation(s)
- C Maurer
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, 81675, München, Germany
| | - J Y Wagner
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - R M Schmid
- II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Strasse 22, 81675, München, Germany
| | - B Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Abstract
Hyperglycaemic hyperosmolar state (HHS) is a medical emergency, which differs from diabetic ketoacidosis (DKA) and requires a different approach. The present article summarizes the recent guidance on HHS that has been produced by the Joint British Diabetes Societies for Inpatient Care, available in full at http://www.diabetologists-abcd.org.uk/JBDS/JBDS_IP_HHS_Adults.pdf. HHS has a higher mortality rate than DKA and may be complicated by myocardial infarction, stroke, seizures, cerebral oedema and central pontine myelinolysis and there is some evidence that rapid changes in osmolality during treatment may be the precipitant of central pontine myelinolysis. Whilst DKA presents within hours of onset, HHS comes on over many days, and the dehydration and metabolic disturbances are more extreme. The key points in these HHS guidelines include: (1) monitoring of the response to treatment: (i) measure or calculate the serum osmolality regularly to monitor the response to treatment and (ii) aim to reduce osmolality by 3-8 mOsm/kg/h; (2) fluid and insulin administration: (i) use i.v. 0.9% sodium chloride solution as the principal fluid to restore circulating volume and reverse dehydration, (ii) fluid replacement alone will cause a fall in blood glucose (BG) level, (iii) withhold insulin until the BG level is no longer falling with i.v. fluids alone (unless ketonaemic), (iv) an initial rise in sodium level is expected and is not itself an indication for hypotonic fluids and (v) early use of insulin (before fluids) may be detrimental; and (3) delivery of care: (i) The diabetes specialist team should be involved as soon as possible and (ii) patients should be nursed in areas where staff are experienced in the management of HHS.
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Affiliation(s)
- A R Scott
- Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
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Barski L, Bartal C, Sagy I, Jotkowitz A, Nevzorov R, Zeller L, Dizengof V, Rogachev B. Seasonal influence on the renal function in hospitalized elderly patients. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2014.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Frangeskou M, Lopez-Valcarcel B, Serra-Majem L. Dehydration in the Elderly: A Review Focused on Economic Burden. J Nutr Health Aging 2015; 19:619-27. [PMID: 26054498 DOI: 10.1007/s12603-015-0491-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dehydration is the most common fluid and electrolyte problem among elderly patients. It is reported to be widely prevalent and costly to individuals and to the health care system. The purpose of this review is to summarize the literature on the economic burden of dehydration in the elderly. METHOD A comprehensive search of several databases from database inception to November 2013, only in English language, was conducted. The databases included Pubmed and ISI Web of Science. The search terms «dehydration» / "hyponaremia" / "hypernatremia" AND «cost» AND «elderly» were used to search for comparative studies of the economic burden of dehydration. A total of 15 papers were identified. RESULTS Dehydration in the elderly is an independent factor of higher health care expenditures. It is directly associated with an increase in hospital mortality, as well as with an increase in the utilization of ICU, short and long term care facilities, readmission rates and hospital resources, especially among those with moderate to severe hyponatremia. CONCLUSIONS Dehydration represents a potential target for intervention to reduce healthcare expenditures and improve patients' quality of life.
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Affiliation(s)
- M Frangeskou
- Dr. Lluis Serra Majem, Research Institute of Biomedical and Health Sciencies, University of Las Palmas de Gran Canaria, PO Box 550; 35080-Las Palmas de Gran Canaria, Spain. Telephone:+34 928 453476 Fax:+34 928 453475 E-mail address:
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Hooper L, Abdelhamid A, Attreed NJ, Campbell WW, Channell AM, Chassagne P, Culp KR, Fletcher SJ, Fortes MB, Fuller N, Gaspar PM, Gilbert DJ, Heathcote AC, Kafri MW, Kajii F, Lindner G, Mack GW, Mentes JC, Merlani P, Needham RA, Olde Rikkert MGM, Perren A, Powers J, Ranson SC, Ritz P, Rowat AM, Sjöstrand F, Smith AC, Stookey JJD, Stotts NA, Thomas DR, Vivanti A, Wakefield BJ, Waldréus N, Walsh NP, Ward S, Potter JF, Hunter P. Clinical symptoms, signs and tests for identification of impending and current water-loss dehydration in older people. Cochrane Database Syst Rev 2015; 2015:CD009647. [PMID: 25924806 PMCID: PMC7097739 DOI: 10.1002/14651858.cd009647.pub2] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is evidence that water-loss dehydration is common in older people and associated with many causes of morbidity and mortality. However, it is unclear what clinical symptoms, signs and tests may be used to identify early dehydration in older people, so that support can be mobilised to improve hydration before health and well-being are compromised. OBJECTIVES To determine the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs and tests to be used as screening tests for detecting water-loss dehydration in older people by systematically reviewing studies that have measured a reference standard and at least one index test in people aged 65 years and over. Water-loss dehydration was defined primarily as including everyone with either impending or current water-loss dehydration (including all those with serum osmolality ≥ 295 mOsm/kg as being dehydrated). SEARCH METHODS Structured search strategies were developed for MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL, LILACS, DARE and HTA databases (The Cochrane Library), and the International Clinical Trials Registry Platform (ICTRP). Reference lists of included studies and identified relevant reviews were checked. Authors of included studies were contacted for details of further studies. SELECTION CRITERIA Titles and abstracts were scanned and all potentially relevant studies obtained in full text. Inclusion of full text studies was assessed independently in duplicate, and disagreements resolved by a third author. We wrote to authors of all studies that appeared to have collected data on at least one reference standard and at least one index test, and in at least 10 people aged ≥ 65 years, even where no comparative analysis has been published, requesting original dataset so we could create 2 x 2 tables. DATA COLLECTION AND ANALYSIS Diagnostic accuracy of each test was assessed against the best available reference standard for water-loss dehydration (serum or plasma osmolality cut-off ≥ 295 mOsm/kg, serum osmolarity or weight change) within each study. For each index test study data were presented in forest plots of sensitivity and specificity. The primary target condition was water-loss dehydration (including either impending or current water-loss dehydration). Secondary target conditions were intended as current (> 300 mOsm/kg) and impending (295 to 300 mOsm/kg) water-loss dehydration, but restricted to current dehydration in the final review.We conducted bivariate random-effects meta-analyses (Stata/IC, StataCorp) for index tests where there were at least four studies and study datasets could be pooled to construct sensitivity and specificity summary estimates. We assigned the same approach for index tests with continuous outcome data for each of three pre-specified cut-off points investigated.Pre-set minimum sensitivity of a useful test was 60%, minimum specificity 75%. As pre-specifying three cut-offs for each continuous test may have led to missing a cut-off with useful sensitivity and specificity, we conducted post-hoc exploratory analyses to create receiver operating characteristic (ROC) curves where there appeared some possibility of a useful cut-off missed by the original three. These analyses enabled assessment of which tests may be worth assessing in further research. A further exploratory analysis assessed the value of combining the best two index tests where each had some individual predictive ability. MAIN RESULTS There were few published studies of the diagnostic accuracy of state (one time), minimally invasive clinical symptoms, signs or tests to be used as screening tests for detecting water-loss dehydration in older people. Therefore, to complete this review we sought, analysed and included raw datasets that included a reference standard and an index test in people aged ≥ 65 years.We included three studies with published diagnostic accuracy data and a further 21 studies provided datasets that we analysed. We assessed 67 tests (at three cut-offs for each continuous outcome) for diagnostic accuracy of water-loss dehydration (primary target condition) and of current dehydration (secondary target condition).Only three tests showed any ability to diagnose water-loss dehydration (including both impending and current water-loss dehydration) as stand-alone tests: expressing fatigue (sensitivity 0.71 (95% CI 0.29 to 0.96), specificity 0.75 (95% CI 0.63 to 0.85), in one study with 71 participants, but two additional studies had lower sensitivity); missing drinks between meals (sensitivity 1.00 (95% CI 0.59 to 1.00), specificity 0.77 (95% CI 0.64 to 0.86), in one study with 71 participants) and BIA resistance at 50 kHz (sensitivities 1.00 (95% CI 0.48 to 1.00) and 0.71 (95% CI 0.44 to 0.90) and specificities of 1.00 (95% CI 0.69 to 1.00) and 0.80 (95% CI 0.28 to 0.99) in 15 and 22 people respectively for two studies, but with sensitivities of 0.54 (95% CI 0.25 to 0.81) and 0.69 (95% CI 0.56 to 0.79) and specificities of 0.50 (95% CI 0.16 to 0.84) and 0.19 (95% CI 0.17 to 0.21) in 21 and 1947 people respectively in two other studies). In post-hoc ROC plots drinks intake, urine osmolality and axillial moisture also showed limited diagnostic accuracy. No test was consistently useful in more than one study.Combining two tests so that an individual both missed some drinks between meals and expressed fatigue was sensitive at 0.71 (95% CI 0.29 to 0.96) and specific at 0.92 (95% CI 0.83 to 0.97).There was sufficient evidence to suggest that several stand-alone tests often used to assess dehydration in older people (including fluid intake, urine specific gravity, urine colour, urine volume, heart rate, dry mouth, feeling thirsty and BIA assessment of intracellular water or extracellular water) are not useful, and should not be relied on individually as ways of assessing presence or absence of dehydration in older people.No tests were found consistently useful in diagnosing current water-loss dehydration. AUTHORS' CONCLUSIONS There is limited evidence of the diagnostic utility of any individual clinical symptom, sign or test or combination of tests to indicate water-loss dehydration in older people. Individual tests should not be used in this population to indicate dehydration; they miss a high proportion of people with dehydration, and wrongly label those who are adequately hydrated.Promising tests identified by this review need to be further assessed, as do new methods in development. Combining several tests may improve diagnostic accuracy.
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Johnson P, Waldreus N, Hahn RG, Stenström H, Sjöstrand F. Fluid retention index predicts the 30-day mortality in geriatric care. Scandinavian Journal of Clinical and Laboratory Investigation 2015; 75:444-51. [DOI: 10.3109/00365513.2015.1039057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Janssens U, Kluge S. Indikation und Steuerung der Volumentherapie. Med Klin Intensivmed Notfmed 2015; 110:110-7. [DOI: 10.1007/s00063-015-0001-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 12/22/2014] [Indexed: 01/28/2023]
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Validation analysis of a geriatric dehydration screening tool in community-dwelling and institutionalized elderly people. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2015; 12:2700-17. [PMID: 25739005 PMCID: PMC4377927 DOI: 10.3390/ijerph120302700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/16/2015] [Indexed: 02/06/2023]
Abstract
Dehydration is common among elderly people. The aim of this study was to perform validation analysis of a geriatric dehydration-screening tool (DST) in the assessment of hydration status in elderly people. This tool was based on the DST proposed by Vivanti et al., which is composed by 11 items (four physical signs of dehydration and seven questions about thirst sensation, pain and mobility), with four questions extra about drinking habits. The resulting questionnaire was evaluated in a convenience sample comprising institutionalized (n = 29) and community-dwelling (n = 74) elderly people. Urinary parameters were assessed (24-h urine osmolality and volume) and free water reserve (FWR) was calculated. Exploratory factor analysis was used to evaluate the scale’s dimensionality and Cronbach’s alpha was used to measure the reliability of each subscale. Construct’s validity was tested using linear regression to estimate the association between scores in each dimension and urinary parameters. Two factors emerged from factor analysis, which were named “Hydration Score” and “Pain Score”, and both subscales showed acceptable reliabilities. The “Hydration Score” was negatively associated with 24-h urine osmolality in community-dwelling; and the “Pain Score” was negatively associated with 24-h urine osmolality, and positively associated with 24-h urine volume and FWR in institutionalized elderly people.
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Abstract
Elder abuse and neglect are highly prevalent but woefully underdetected and underreported. The presentation is rarely clear and requires the piecing together of clues that create a mosaic of the full picture. More research needed to better characterize findings that, when identified, can contribute to certainty in cases of suspected abuse. Medical and laboratory data can be helpful in the successful determination of abuse and neglect.
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Affiliation(s)
- Veronica M LoFaso
- New York Presbyterian Hospital, Weill Cornell Medical College, Box 39, 525 East 68th Street, New York, NY 10065, USA.
| | - Tony Rosen
- New York Presbyterian Hospital, Weill Cornell Medical College, Box 39, 525 East 68th Street, New York, NY 10065, USA
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van Melick EJM, Wilting I, Ziere G, Kok RM, Egberts TCG. The influence of lithium on calcium homeostasis in older patients in daily clinical practice. Int J Geriatr Psychiatry 2014; 29:594-601. [PMID: 24311305 DOI: 10.1002/gps.4041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 09/01/2013] [Accepted: 10/02/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND Lithium can influence calcium homeostasis resulting in changes in parathormone set point and renal calcium handling. The clinical significance of these changes in older patients is unknown. The objective of this study was to investigate the possible association between duration of lithium treatment and corrected calcium, parathormone and 24-h urinary calcium excretion in older psychiatric patients corrected for renal function and vitamin 25OH D and also to estimate the point prevalence of hypercalcemia and raised parathormone. METHODS A cross-sectional study of psychiatric outpatients visiting a specialized facility for older patients treated with lithium was performed. Patients underwent a comprehensive assessment and blood and urine testing. Potential confounders of calcium homeostasis were recorded. On the basis of the duration of lithium treatment, patients were divided into four groups. RESULTS One hundred eleven patients were included, mean age 75.2 years. There was no significant association between the duration of lithium treatment and corrected calcium, parathormone and 24-h urinary calcium excretion. The point prevalence of hypercalcemia was 2.7% and 47.8% for raised parathormone. There was an unexpected but significant negative association between the duration of lithium treatment and vitamin 25OH D, with 76.9% vitamin 25OH D deficiency (<50 nmol/L) in the group using lithium for more than 10 years. CONCLUSIONS No association was found between duration of lithium treatment and calcium parameters in older psychiatric outpatients, but there was a high prevalence of raised parathormone and an unexpected negative association between duration of lithium treatment and 25OH D.
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Wright HE, Larose J, McLellan TM, Hardcastle SG, Boulay P, Kenny GP. Moderate-intensity intermittent work in the heat results in similar low-level dehydration in young and older males. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2014; 11:144-53. [PMID: 24521064 DOI: 10.1080/15459624.2013.817676] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Older individuals may be more susceptible to the negative thermal and cardiovascular consequences of dehydration during intermittent work in the heat. This study examined the hydration, thermal, and cardiovascular responses to intermittent exercise in the heat in 14 Young (Y, Mean ± SE; 25.8 ± 0.8 years), Middle-age (MA, 43.6 ± 0.9 years), and Older (O, 57.2 ± 1.5 years) healthy, non-heat acclimated males matched for height, mass, body surface area, and percent body fat. Rectal temperature (Tre), heart rate (HR), local sweat rate (LSR), and hydration indices were measured during 4 × 15-min moderate to heavy cycling bouts at 400 W heat production, each followed by a 15-min rest period, in Warm/Dry (35°C, 20% relative humidity [RH]) and Warm/Humid (35°C, 60% RH) heat. No differences were observed between the age groups for Tre, Tre change, HR, LSR, mass change, urine specific gravity, and plasma protein concentration in either condition, irrespective of the greater level of thermal and cardiovascular strain experienced in the Warm/Humid environment. Plasma volume changes (Dry Y: -5.4 ± 0.7, MA: -6.2 ± 0.9, O: -5.7 ± 0.9%, Humid Y: -7.3 ± 1.0, MA: -7.9 ± 0.8, O: -8.4 ± 1.0%) were similar between groups, as were urine specific gravity and plasma protein concentrations. Thus, physically active Young, Middle-age, and Older males demonstrate similar hydration, thermal, and cardiovascular responses during moderate- to high-intensity intermittent exercise in the heat.
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Affiliation(s)
- Heather E Wright
- a Human and Environmental Physiology Research Unit, School of Human Kinetics , University of Ottawa , Ottawa , Canada
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Water-loss dehydration and aging. Mech Ageing Dev 2013; 136-137:50-8. [PMID: 24333321 DOI: 10.1016/j.mad.2013.11.009] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 11/12/2013] [Accepted: 11/27/2013] [Indexed: 11/21/2022]
Abstract
This review defines water-loss and salt-loss dehydration. For older people serum osmolality appears the most appropriate gold standard for diagnosis of water-loss dehydration, but clear signs of early dehydration have not been developed. In older adults, lower muscle mass, reduced kidney function, physical and cognitive disabilities, blunted thirst, and polypharmacy all increase dehydration risk. Cross-sectional studies suggest a water-loss dehydration prevalence of 20-30% in this population. Water-loss dehydration is associated with higher mortality, morbidity and disability in older people, but evidence is still needed that this relationship is causal. There are a variety of ways we may be able to help older people reduce their risk of dehydration by recognising that they are not drinking enough, and being helped to drink more. Strategies to increase fluid intake in residential care homes include identifying and overcoming individual and institutional barriers to drinking, such as being worried about not reaching the toilet in time, physical inability to make or to reach drinks, and reduced social drinking and drinking pleasure. Research needs are discussed, some of which will be addressed by the FP7-funded NU-AGE (New dietary strategies addressing the specific needs of elderly population for a healthy ageing in Europe) trial.
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Abstract
Nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex, because of preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration); as well as intensive care unit-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration in the critically ill older adult, reviews assessment principles, and offers strategies for optimizing nutrition and hydration.
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Lamantia MA, Stewart PW, Platts-Mills TF, Biese KJ, Forbach C, Zamora E, McCall BK, Shofer FS, Cairns CB, Busby-Whitehead J, Kizer JS. Predictive value of initial triage vital signs for critically ill older adults. West J Emerg Med 2013; 14:453-60. [PMID: 24106542 PMCID: PMC3789908 DOI: 10.5811/westjem.2013.5.13411] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 04/24/2013] [Accepted: 05/21/2013] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Triage of patients is critical to patient safety, yet no clear information exists as to the utility of initial vital signs in identifying critically ill older emergency department (ED) patients. The objective of this study is to evaluate a set of initial vital sign thresholds as predictors of severe illness and injury among older adults presenting to the ED. METHODS We reviewed all visits by patients aged 75 and older seen during 2007 at an academic ED serving a large community of older adults. Patients' charts were abstracted for demographic and clinical information including vital signs, via automated electronic methods. We used bivariate analysis to investigate the relationship between vital sign abnormalities and severe illness or injury, defined as intensive care unit (ICU) admission or ED death. In addition, we calculated likelihood ratios for normal and abnormal vital signs in predicting severe illness or injury. RESULTS 4,873 visits by patients aged 75 and above were made to the ED during 2007, and of these 3,848 had a complete set of triage vital signs. For these elderly patients, the sensitivity and specificity of an abnormal vital sign taken at triage for predicting death or admission to an ICU were 73% (66,81) and 50% (48,52) respectively (positive likelihood ratio 1.47 (1.30,1.60); negative likelihood ratio 0.54 (0.30,0.60). CONCLUSION Emergency provider assessment and triage scores that rely primarily on initial vital signs are likely to miss a substantial portion of critically ill older adults.
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Affiliation(s)
- Michael A Lamantia
- Indiana University Center for Aging Research and Regenstrief Institute, Indianapolis, Indiana
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Nwosu AC, Mayland CR, Mason SR, Khodabukus AF, Varro A, Ellershaw JE. Hydration in advanced cancer: can bioelectrical impedance analysis improve the evidence base? A systematic review of the literature. J Pain Symptom Manage 2013. [PMID: 23200189 DOI: 10.1016/j.jpainsymman.2012.08.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
CONTEXT Decisions surrounding the administration of clinically assisted hydration to patients dying of cancer can be challenging because of the limited understanding of hydration in advanced cancer and a lack of evidence to guide health care professionals. Bioelectrical impedance analysis (BIA) has been used to assess hydration in various patient groupings, but evidence for its use in advanced cancer is limited. OBJECTIVES To critically appraise existing methods of hydration status assessment in advanced cancer and review the potential for BIA to assess hydration in advanced cancer. METHODS Searches were carried out in four electronic databases. A hand search of selected peer-reviewed journals and conference abstracts also was conducted. Studies reporting (de)hydration assessment (physical examination, biochemical measures, symptom assessment, and BIA) in patients with advanced cancer were included. RESULTS The results highlight how clinical examination and biochemical tests are standard methods of assessing hydration, but limitations exist with these methods in advanced cancer. Furthermore, there is disagreement over the evidence for some commonly associated symptoms with dehydration in cancer. Although there are limitations with using BIA alone to assess hydration in advanced cancer, analysis of BIA raw measurements through the method of bioelectrical impedance vector analysis may have a role in this population. CONCLUSION The benefits and burdens of providing clinically assisted hydration to patients dying of cancer are unclear. Bioelectrical impedance vector analysis shows promise as a hydration assessment tool but requires further study in advanced cancer. Innovative methodologies for research are required to add to the evidence base and ultimately improve the care for the dying.
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Affiliation(s)
- Amara Callistus Nwosu
- Marie Curie Palliative Care Institute Liverpool, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.
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Vivanti A, Yu L, Palmer M, Dakin L, Sun J, Campbell K. Short-term body weight fluctuations in older well-hydrated hospitalised patients. J Hum Nutr Diet 2013; 26:429-35. [DOI: 10.1111/jhn.12034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- A. Vivanti
- Department of Nutrition and Dietetics; Princess Alexandra Hospital; Brisbane QLD Australia
| | - L. Yu
- School of Public Health; Griffith University; Gold Coast QLD Australia
| | - M. Palmer
- School of Public Health; Griffith University; Gold Coast QLD Australia
| | - L. Dakin
- Geriatrics and Rehabilitation Unit; Princess Alexandra Hospital; Brisbane QLD Australia
| | - J. Sun
- School of Public Health; Griffith University; Gold Coast QLD Australia
| | - K. Campbell
- Department of Nutrition and Dietetics; Princess Alexandra Hospital; Brisbane QLD Australia
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Variables influencing the frictional behaviour of in vivo human skin. J Mech Behav Biomed Mater 2013; 28:448-61. [PMID: 23796756 DOI: 10.1016/j.jmbbm.2013.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 02/12/2013] [Accepted: 02/18/2013] [Indexed: 01/16/2023]
Abstract
In the past decades, skin friction research has focused on determining which variables are important to affect the frictional behaviour of in vivo human skin. Until now, there is still limited knowledge on these variables. This study has used a large dataset to identify the effect of variables on the human skin, subject characteristics and environmental conditions on skin friction. The data are obtained on 50 subjects (34 males and 16 females). Friction measurements represent the friction between in vivo human skin and an aluminium sample, assessed on three anatomical locations. The coefficient of friction increased significantly (p<0.05) with increasing age, increasing ambient temperature and increasing relative air humidity. A significant inversely proportional relationship was found between friction and both the amount of hair present on the skin and the height of the subject. Other outcome variables in this study were the hydration of the skin and the skin temperature.
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