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Flim M, Rustøen T, Blackwood B, Spronk PE. Thirst in adult patients in the intensive care unit: A scoping review. Intensive Crit Care Nurs 2024; 86:103787. [PMID: 39182324 DOI: 10.1016/j.iccn.2024.103787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/26/2024] [Accepted: 07/30/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE To review the literature on thirst in intensive care unit (ICU) patients and report potential causes, risk factors, diagnosis and measurement tools, as well as potential co-occurrence with other distressing symptoms, and the management of thirst in the ICU. DESIGN A scoping review employing the Joanna Briggs Institute methodology. METHODS PubMed, MEDLINE, EMBASE and CINAHL were searched from inception to April 2024. Any type of empirical study reporting thirst or associated xerostomia in adult patients (≥18 years) admitted to an ICU or high dependency unit for more than 24 h were included. RESULTS The search yielded 907 unique records, and after evaluating 65 full-text publications, 21 studies were included. Thirst intensity was addressed most often (eleven studies), whereas the experience (or quality) of thirst and the validation of a measurement instrument, were addressed in only one study. Although co-occurrence of symptoms was addressed in four studies, only one pilot study looked into the interaction of thirst with other symptoms. Intervention studies have been focussing primarily on mouth-care interventions. CONCLUSION Thirst is a distressing symptom in the ICU, with reported high prevalence and intensity. Knowledge about its causes, interventions that incorporate minimising its risk, occurrence and intensity are limited. IMPLICATIONS FOR CLINICAL PRACTICE Health care providers should acknowledge thirst as a prominent symptom for ICU patients. They should possess knowledge on the factors that potentially evoke or aggravate thirst. Regular and timely relief of thirst by oral care with cold swabs and the application of menthol can be regarded as a first choice of intervention.
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Affiliation(s)
- Marleen Flim
- Gelre Hospitals, department of intensive care, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, the Netherlands; Expertise centre for Intensive Care Rehabilitation Apeldoorn (ExpIRA), Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, the Netherlands.
| | - Tone Rustøen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Kirkeveien 166, 0450 Oslo, Norway; Institute of Health and Society, Faculty of Medicine, University of Oslo, PD 1089 Blindern, 0318 Oslo, Norway
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, 97 Lisburn road, Belfast BT9 7BL, Northern Ireland
| | - Peter E Spronk
- Gelre Hospitals, department of intensive care, Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, the Netherlands; Expertise centre for Intensive Care Rehabilitation Apeldoorn (ExpIRA), Albert Schweitzerlaan 31, 7334 DZ Apeldoorn, the Netherlands
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Mert S, Çalışkan İ, Koruk S. The Effect of Menthol Ice on Laparoscopic Cholecystectomy Patients' Thirst, Dry Mouth, Mouth Taste, and Bad Mouth Odor: A Randomized Controlled Trial. J Perianesth Nurs 2024:S1089-9472(23)01114-0. [PMID: 38795086 DOI: 10.1016/j.jopan.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 05/27/2024]
Abstract
PURPOSE This study aimed to determine the effect of menthol ice application on thirst, dry mouth, mouth taste, and bad mouth odor in patients who underwent laparoscopic cholecystectomy in the postoperative period. DESIGN The study was conducted as a randomized controlled trial with an experimental design. METHODS The study sample consisted of 90 patients who underwent laparoscopic cholecystectomy and met the inclusion criteria. Patients were divided into three groups by randomization program. Patients in the menthol ice and ice popsicle (ice prepared with drinking water only) group were administered menthol ice/ice popsicle (10 mL) twice at 20 minutes intervals. Patients in the control group did not receive any intervention. Routine practices of the clinic were performed by the nurses of the general surgery clinic. Postoperative thirst intensity, severity of dry mouth, bad taste, and bad odor in the mouth were evaluated at 0, 20, and 40 minutes. FINDINGS No statistically significant difference was found between the sociodemographic and clinical characteristics of the patients in the control group, menthol ice group, and ice popsicle group (P > .05). A statistically significant difference was found between the 3 groups in terms of thirst intensity and severity of dry mouth at times at the 20th and 40th minutes after the application (P < .01). We found a statistically significant difference between the bad taste and bad odor sensation scores of the patients in the control and intervention groups at the 20th and 40th minutes after the application (P < .05). CONCLUSIONS The study concluded that menthol ice and ice popsicle application are effective strategies to reduce the intensity of thirst, severity of dry mouth, bad taste, and bad odor in postoperative patients.
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Affiliation(s)
- Sabiha Mert
- İstanbul Galata University, Vocational School, Anesthesia program, İstanbul, Turkey
| | - İlknur Çalışkan
- Izmir Tinaztepe Unıversity, Faculty of Health Sciences, Department of Nursing, Izmir, Turkey.
| | - Senem Koruk
- Istanbul Medeniyet University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İstanbul, Turkey
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Çelik SŞ, Mert S, Arslan HN. The Effect of Cold Oral Applications in the Management of Postoperative Thirst: A Systematic Review. J Perianesth Nurs 2024:S1089-9472(23)01064-X. [PMID: 38556965 DOI: 10.1016/j.jopan.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/16/2023] [Accepted: 11/28/2023] [Indexed: 04/02/2024]
Abstract
PURPOSE Thirst is one of the most bothersome symptoms experienced by surgical patients. Effective thirst intervention and management in the Post Anesthesia Care Unit (PACU) and hospital wards is critical because patients are less sedated and more aware than in the past. There is a need to review the literature on the identification and management of thirst in the inpatient and PACU settings. The aim of this systematic review was to examine the available evidence on the effectiveness of oral cold applications on thirst in postoperative patients. DESIGN This was a systematic review study. Articles in PUBMED, Web of Science, ScienceDirect, TÜBİTAK-ULAKBİM, and TRDizin databases between January 2008 and January 2023 that included oral cold applications to relieve the thirst of patients in the postoperative period were included. METHODS The PICOT-SD (Patients Interventions Comparison Outcome Time-Study Design) method was used as an eligibility criterion for inclusion in the study. The eligibility criteria included that the articles were written in English-Turkish and within the target dates, the studies included nursing interventions, the primary outcome of the studies was thirst, and the study sample included postoperative patients. The risk of bias was assessed using the RoB2 tool developed by Cochrane. FINDINGS A total of 254 articles were retrieved from the databases using the specified keywords. 244 articles did not meet the study criteria: 30 were excluded because they were not interventional studies, 61 were not conducted in a postoperative population, 56 were duplicates, and 79 were not on a related topic. A total of 10 studies consisting of randomized controlled trials and quasi-experimental articles met the criteria for our review. Oral cold applications effectively reduced the thirst rate of postoperative patients and improved their health-related quality of life. The intervention has also been shown to reduce other anesthesia-related complications. CONCLUSIONS This systematic review concluded that cold oral applications have promising effects on thirst, dry mouth, and health-related quality of life. Cold oral applications are cost-effective and suitable for large-scale health care applications.
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Affiliation(s)
| | - Sabiha Mert
- Istanbul Galata University, Vocational School, Anesthesia Program, Istanbul, Turkey
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Hassan AM, Nogueira L, Lin YL, Rogers JE, Nori-Sarma A, Offodile AC. Impact of Heatwaves on Cancer Care Delivery: Potential Mechanisms, Health Equity Concerns, and Adaptation Strategies. J Clin Oncol 2023:JCO2201951. [PMID: 37098249 DOI: 10.1200/jco.22.01951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/27/2023] Open
Affiliation(s)
- Abbas M Hassan
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Yu-Li Lin
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jane E Rogers
- Pharmacy Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amruta Nori-Sarma
- Department of Environmental Health, Boston University School of Public Health, Boston, MA
| | - Anaeze Chidiebele Offodile
- Department of Plastic & Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX
- Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX
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Zhang W, Gu Q, Gu Y, Zhao Y, Zhu L. Symptom management to alleviate thirst and dry mouth in critically ill patients: A randomised controlled trial. Aust Crit Care 2022; 35:123-129. [PMID: 34119409 DOI: 10.1016/j.aucc.2021.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/22/2021] [Accepted: 04/17/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Critically ill patients often experience coexisting symptoms. Thirst, in particular, appears to be an important symptom, having the highest prevalence, intensity, and induction of distress, and is significantly correlated with other symptoms. However, thirst and dry mouth are not usually assessed or treated. OBJECTIVES The aim of the study was to demonstrate the effectiveness of an intervention bundle to relieve thirst and dry mouth. METHODS The present study was a randomised controlled trial in which critically ill patients were allocated to an experimental or control group. The intervention bundles, including vitamin C sprays, peppermint water mouthwash, and a lip moisturiser, were provided to the experimental group for 3 days, whereas patients in the control group were exposed to the placebo interventions, including saline sprays, 40 °C water mouthwash, and wetting the lips with water. RESULTS A total of 61 patients were recruited to the study; 65.6% (n = 41) were men, and the average age was 64.2 ± 16.8 years. The average decrease in thirst intensity and oral mucosa situation scores after the interventions was larger in the experimental group patients relative to controls (1.27 and 0.36 vs. 0.19 and 0.1 points, respectively; p < 0.05). Being male, scoring highly on the Acute Physiology and Chronic Health Evaluation II scale, not receiving diuretics, and having higher serum sodium levels were potential predictors of thirst and oral dryness. CONCLUSIONS The interventional bundle used in this study was shown to be a promising approach that can relieve thirst intensity and dry mouth, which are pervasively distressful to critically ill patients. CLINICAL TRIAL REGISTRATION NUMBERS The study was registered on the www.Chictr.org.cn under the identification number ChiCTR1900022873.
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Affiliation(s)
- Weiqing Zhang
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiuying Gu
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Yanting Gu
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yujin Zhao
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Zhu
- Department of Critical Care Medicine, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Negro A, Villa G, Greco M, Ciriolo E, Luraschi EL, Scaramuzzi J, Manara DF, Zangrillo A. Thirst in patients admitted to intensive care units: an observational study. Ir J Med Sci 2021; 191:2283-2289. [PMID: 34668107 PMCID: PMC8526093 DOI: 10.1007/s11845-021-02817-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/13/2021] [Indexed: 12/02/2022]
Abstract
Background Despite various studies reporting a high prevalence, reaching 71%, the sensation of thirst in intensive care unit (ICU) patients, its prevention, detection, and management, is not well known nor considered. Limited research has examined the causes of thirst in ICU patients, while it has been examined in other patient populations. Aim To determine the incidence and intensity of thirst in patients admitted to ICU and its association with airway devices (endotracheal tube, tracheostomy, oxygen mask), airway humidification, patients’ characteristics, and therapy (serum sodium concentration, hematocrit, fluid balance, possibility of oral hydration, and dosage of diuretics). Methods Patients were interviewed daily to report the presence of thirst and rate its intensity on a Numeric Rating Scale (NRS) from 0 (no thirst) –10 (intolerable thirst). Other data were obtained through direct evaluation or by consulting medical records. Patients admitted to three ICUs from May to August 2014 in a university hospital in Italy were included. Results A total of 220 Patients were enrolled. Thirst was found in 76.1% of patients’ observations, with a mean thirst score of 5.37. Thirst intensity was predicted by high doses of diuretics (> 100 mg/die), increasing serum sodium concentration, absence of oral hydration and the presence of xerostomia. Thirst was associated with the use of humidified Venturi mask. Conclusions Thirst is highly prevalent among patients in this population of intensive care patients. It would be desirable to evaluate this stressor at least daily, to eliminate or relieve this sensation.
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Affiliation(s)
| | - Giulia Villa
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy.
| | | | | | | | | | - Duilio Fiorenzo Manara
- Center for Nursing Research and Innovation, Vita-Salute San Raffaele University, Via Olgettina, 58, 20132, Milan, Italy
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de Vries F, Lobatto DJ, Verstegen MJT, van Furth WR, Pereira AM, Biermasz NR. Postoperative diabetes insipidus: how to define and grade this complication? Pituitary 2021; 24:284-291. [PMID: 32990908 PMCID: PMC7966184 DOI: 10.1007/s11102-020-01083-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Although transient diabetes insipidus (DI) is the most common complication of pituitary surgery, there is no consensus on its definition. Polyuria is the most overt symptoms of DI, but can also reflect several physiological adaptive mechanisms in the postoperative phase. These may be difficult to distinguish from and might coincide with DI. The difficulty to distinguish DI from other causes of postoperative polyuria might explain the high variation in incidence rates. This limits interpretation of outcomes, in particular complication rates between centers, and may lead to unnecessary treatment. Aim of this review is to determine a pathophysiologically sound and practical definition of DI for uniform outcome evaluations and treatment recommendations. METHODS This study incorporates actual data and the experience of our center and combines this with a review of literature on pathophysiological mechanisms and definitions used in clinical studies reporting of postoperative DI. RESULTS The occurrence of excessive thirst and/or hyperosmolality or hypernatremia are the best indicators to discriminate between pathophysiological symptoms and signs of DI and other causes. Urine osmolality distinguishes DI from osmotic diuresis. CONCLUSIONS To improve reliability and comparability we propose the following definition for postoperative DI: polyuria (urine production > 300 ml/hour for 3 h) accompanied by a urine specific gravity (USG) < 1.005, and at least one of the following symptoms: excessive thirst, serum osmolality > 300 mosmol/kg, or serum sodium > 145 mmol/L. To prevent unnecessary treatment with desmopressin, we present an algorithm for the diagnosis and treatment of postoperative DI.
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Affiliation(s)
- Friso de Vries
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden, Postbox 9600, 2300 RC, The Netherlands.
- Centre for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands.
| | - Daniel J Lobatto
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
- Centre for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
| | - Marco J T Verstegen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
- Centre for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
- Centre for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden, Postbox 9600, 2300 RC, The Netherlands
- Centre for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, Leiden, Postbox 9600, 2300 RC, The Netherlands
- Centre for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, Postbox 9600, 2300 RC, Leiden, The Netherlands
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Jörres M, Gunga HC, Steinach M. Physiological Changes, Activity, and Stress During a 100-km-24-h Walking-March. Front Physiol 2021; 12:640710. [PMID: 33776795 PMCID: PMC7991843 DOI: 10.3389/fphys.2021.640710] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background Long-endurance exercises like ultramarathons are known to elicit various metabolic and physiological changes in the human body. However, little is known about very long-duration exercise at low intensities regarding healthy human subjects. Aim The purpose of this study was to evaluate changes in body composition and metabolism in long-endurance but low-intensity events. Methods Twenty-five male and 18 female healthy recreational athletes (age 34.6 ± 8.8 years; BMI: 22.4 ± 2.0 kg/m2) of the "100 km Mammutmarsch" were recruited for participation during the events in 2014-2016. Other than classical ultramarathons, the "Mammutmarsch" is a hiking event, in which participants were required to walk but not run or jog. It was expected to complete the 100-km distance within 24 h, resulting in a calculated mean speed of 4.17 km/h, which fits to the mean speed observed (4.12 ± 0.76 km/h). As not all participants reached the finish line, comparison of finishers (FIN, n = 11) and non-finishers (NON, n = 21) allowed differential assessment of performance. Body composition measured through bioelectrical impedance analysis (BIA) was determined pre- and post-event, and serum samples were taken pre-event, at 30, 70, and 100 km to determine NT-pro-BNP, troponin T, C-reactive protein (CRP), cortisol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides, total cholesterol, total creatine kinase (CK), CK-MB, aminotransferase (AST), ALT, and sodium levels. Nineteen participants wore actimeter armbands (SenseWear®) to gain information about body activity and exercise intensity [metabolic equivalent of task (MET)]. Sixteen participants wore mobile heart rate monitors to assess mean heart rate during the race. Serum parameter alterations over the course of the race were analyzed with mixed-effects ANOVA and additional t-tests. All serum parameters were analyzed for correlation concerning different MET levels, speed, age, BMI, baseline NT-pro-BNP, mean heart rate during the race, and sex with linear regression analysis. Results We found significant elevations for muscle and cardiac stress markers (CRP, CK, CK-MB, AST, ALT, cortisol, and NT-pro-BNP) as well as decreasing markers of lipid metabolism (cholesterol, triglycerides, LDL). Although the intensity level demanded from our participants was low compared with other studies on (ultra-) marathons, the alteration of tested parameters was similar to those of high-intensity exercise, e.g., NT-pro-BNP showed a fourfold increase (p < 0.01) and LDL decreased by 20% (p = 0.05). Besides the duration of exercise, age, BMI, training status, and sex are relevant parameters that influence the elevation of stress factors. Notably, our data indicate that NT-pro-BNP might be a marker for cardiovascular fitness also in healthy adults. Conclusion This low-intensity long-endurance walk evoked a strong systemic reaction and large cell stress and shifted to a favorable lipid profile, comparable to higher intensity events. Despite increasing cardiac stress parameters, there were no indications of cardiac cell damage. Remarkably, the duration seems to have a greater influence on stress markers and metabolism than intensity.
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Affiliation(s)
- Marc Jörres
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Physiology, Center for Space Medicine and Extreme Environments, Berlin, Germany
| | - Hanns-Christian Gunga
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Physiology, Center for Space Medicine and Extreme Environments, Berlin, Germany
| | - Mathias Steinach
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Physiology, Center for Space Medicine and Extreme Environments, Berlin, Germany
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Conchon MF, Fonseca LF, Galvão CM. Use of Mentholated Popsicle in the Management of the Elderly Patient's Thirst in the Immediate Postoperative Period: A Randomized Controlled Trial. J Perianesth Nurs 2021; 36:262-267. [PMID: 33640289 DOI: 10.1016/j.jopan.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/02/2020] [Accepted: 09/13/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE This study aimed to compare a mentholated popsicle with usual care (absolute fasting) in the change in thirst intensity and discomfort in elderly patients in the immediate postoperative period (IPP). DESIGN A randomized controlled trial. METHODS The sample consisted of 50 elderly patients (60 years or older) in the IPP who were randomly assigned to two groups: experimental group (20 mL mentholated popsicle) and control group (usual care). The outcomes, thirst intensity and discomfort, were assessed at baseline and 20 minutes after the intervention. FINDINGS The mentholated popsicle presented a statistically significant (P < .001) decrease in thirst intensity and discomfort by 5.0 in the median and a Cohen's r large effect size for both outcomes. There were no adverse events or side effects. CONCLUSIONS The use of a mentholated popsicle decreased the intensity and discomfort of the elderly patient's thirst in the IPP.
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Affiliation(s)
| | | | - Cristina M Galvão
- Ribeirão Preto College of Nursing, University of São Paulo, São Paulo, Brazil
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Nakaya TG, Conchon MF, Garcia AKA, Uchôa ET, Fonseca LF. Effects of the ice popsicle on vasopressin, osmolality, thirst intensity, and thirst discomfort. Rev Gaucha Enferm 2021; 42:e20190449. [PMID: 33566943 DOI: 10.1590/1983-1447.2021.20190449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/05/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To analyze the effects of the ice popsicle on vasopressin, osmolality, thirst intensity, and thirst discomfort. METHOD This is a quasi-experimental, pre- and post-test study conducted in a laboratory. The sample consisted of nine healthy male volunteers, who received 2% hypertonic saline solution. RESULTS Popsicle intake did not result in a statistically significant reduction in vasopressin levels (F=0.876 and p=0.428). However, there was a reduction in the hormonal physiological profile of vasopressin from 7.1 pg/ml to 5.8 pg/ml after the first two interventions. Osmolality concentration changed from 270.65 to 286.51 mOsm/kg, with no statistical difference (F=2.207; p=0.09). Ice popsicles significantly reduced thirst intensity (F=10.00; p=0.001) and thirst discomfort (F=10.528; p <0.001). CONCLUSION There was a reduction in thirst intensity and discomfort after the use of the 20 ml ice popsicle. There was no statistical difference for vasopressin and osmolality. However, there was a reduction in the hormonal physiological profile of vasopressin during 30 minutes of intervention.
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Affiliation(s)
- Thammy Gonçalves Nakaya
- Universidade Estadual de Londrina (UEL), Programa de Pós-graduação em Enfermagem. Departamento de Enfermagem. Londrina, Paraná, Brasil
| | - Marilia Ferrari Conchon
- Universidade Estadual de Londrina (UEL), Programa de Pós-graduação em Enfermagem. Departamento de Enfermagem. Londrina, Paraná, Brasil
| | - Aline Korki Arrabal Garcia
- Universidade Estadual de Londrina (UEL), Programa de Pós-graduação em Enfermagem. Departamento de Enfermagem. Londrina, Paraná, Brasil
| | - Ernane Torres Uchôa
- Universidade Estadual de Londrina (UEL), Programa de Pós-graduação em Ciências Fisiológicas. Departamento de Fisiologia. Londrina, Paraná, Brasil
| | - Lígia Fahl Fonseca
- Universidade Estadual de Londrina (UEL), Programa de Pós-graduação em Enfermagem. Departamento de Enfermagem. Londrina, Paraná, Brasil
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TEREZA DENISEM, BALDASSO GABRIELAM, PAES RODRIGOS, PACHECO MARIAE, ROSA PATRÍCIAP, VENDRAMINE BEATRIZ, HULSE SERGIOC, CAPASSO RAFFAELE, DUTRA RAFAELC. Evaluation of the protocol for thirst management using ice popsicles in the immediate postoperative period: A pilot study in southern Brazilian hospital. AN ACAD BRAS CIENC 2021. [DOI: 10.1590/0001-3765202120201260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- DENISE M. TEREZA
- Universidade Federal de Santa Catarina, Brazil; Universidade Federal de Santa Catarina, Brazil
| | | | | | | | | | | | | | | | - RAFAEL C. DUTRA
- Universidade Federal de Santa Catarina, Brazil; Universidade Federal de Santa Catarina, Brazil
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Adams JD, Myatich AI, McCullough AS. Thirst as an ingestive behavior: A brief review on physiology and assessment. Nutr Health 2020; 26:271-274. [PMID: 32297552 DOI: 10.1177/0260106020916972] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Thirst is a sensation normally aroused by a lack of water and associated with a desire to drink more fluid. AIM The aims of this brief review are twofold: (a) to summarize the thirst mechanism in how it is initiated and diminished, and (b) to describe techniques to assess human thirst accurately in a variety of situations. DISCUSSION Thirst is maintained via a feedback-controlled mechanism, regulated by central and peripheral factors, as well as social and psychological cues. Most studies of thirst have focused on the initiation of water intake and the neural mechanisms responsible for this vital behavior. Less attention has been paid to the stimuli and mechanisms that terminate a bout of drinking and limit fluid ingestion, such as oropharyngeal and gastric signals, coupled with osmotic sensations. Thirst perception is typically assessed by subjective ratings using a variety of questionnaires, rankings, or visual analog scales. However, the appropriate perceptual tool may not always be used for the correct assessment of thirst perception. CONCLUSIONS In considering the many factors involved in thirst arousal and inhibition, similar questions need to be considered for the correct assessment of this ingestive behavior.
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Affiliation(s)
- J D Adams
- Department of Health and Human Performance, College of Charleston, USA
| | - Ali I Myatich
- Department of Health and Human Performance, College of Charleston, USA
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Carroll HA, Chen YC, Templeman I, James LJ, Betts JA, Trim WV. The effect of hydration status on plasma FGF21 concentrations in humans: A subanalysis of a randomised crossover trial. PLoS One 2020; 15:e0235557. [PMID: 32756564 PMCID: PMC7406048 DOI: 10.1371/journal.pone.0235557] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022] Open
Abstract
Aim Fibroblast growth factor 21 (FGF21) has recently been implicated in thirst in rodent models. The mechanisms for this are currently uncertain, and it is unclear whether hydration status can alter FGF21 concentrations, potentially providing an additional mechanism by which hypohydration induces thirst. The aim of this study is therefore to understand whether hydration status can alter circulating FGF21 in humans. Methods Using a heat tent and fluid restriction, we induced hypohydration (1.9% body mass loss) in 16 healthy participants (n = 8 men), and compared their glycaemic regulation to a rehydration protocol (heat tent and fluid replacement) in a randomised crossover design. Results After the hypohydration procedure, urine specific gravity, urine and serum osmolality, and plasma copeptin (as a marker for arginine vasopressin) increased as expected, with no change after the rehydration protocol. In the fasted state, the median paired difference in plasma FGF21 concentrations from the rehydrated to hypohydrated trial arm was -37 (interquartile range -125, 10) pg∙mL-1(P = 0.278), with average concentrations being 458 ± 462 pg∙mL-1 after hypohydration and 467 ± 438 pg∙mL-1 after rehydration; mean difference -9 ± 173 pg∙mL-1. Conclusion To our knowledge, these are the first causal data in humans investigating hydration and FGF21, demonstrating that an acute bout of hypohydration does not impact fasted plasma FGF21 concentrations. These data may suggest that whilst previous research has found FGF21 administration can induce thirst and drinking behaviours, a physiological state implicated in increased thirst (hypohydration) does not appear to impact plasma FGF21 concentrations in humans.
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Affiliation(s)
- Harriet A. Carroll
- Department for Health, University of Bath, Bath, United Kingdom
- Cardiovascular Research–Hypertension, Clinical Research Centre, Lund University, Malmö, Sweden
- * E-mail:
| | - Yung-Chih Chen
- Department of Physical Education, National Taiwan Normal University, Taipei, Taiwan
- Institute for Research Excellence in Learning Science, National Taiwan Normal University, Taipei, Taiwan
| | - Iain Templeman
- Department for Health, University of Bath, Bath, United Kingdom
| | - Lewis J. James
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - James A. Betts
- Department for Health, University of Bath, Bath, United Kingdom
| | - William V. Trim
- Department for Health, University of Bath, Bath, United Kingdom
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Nascimento LAD, Garcia AKA, Conchon MF, Aroni P, Pierotti I, Martins PR, Nakaya TG, Fonseca LF. Advances in the Management of Perioperative Patients' Thirst. AORN J 2020; 111:165-179. [DOI: 10.1002/aorn.12931] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Evaluation of a Safety Protocol for the Management of Thirst in the Postoperative Period. J Perianesth Nurs 2019; 35:193-197. [PMID: 31864832 DOI: 10.1016/j.jopan.2019.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/25/2019] [Accepted: 07/25/2019] [Indexed: 11/23/2022]
Abstract
PURPOSE To associate medications, anesthetic techniques, and clinical conditions that interfere in the time of patient approval in the safety protocol for thirst management. DESIGN A quantitative, analytical, and longitudinal study conducted in Southern Brazil. METHODS A nonprobabilistic sample, of 203 adult patients in the immediate postoperative period, evaluated every 15 minutes for 1 hour. FINDINGS A general prevalence of thirst of 67.7%, and mean intensity of 6.38. Fentanyl, morphine, rocuronium, and sevoflurane increased lack of approval in the protocol within 30 minutes (P < .05). General anesthesia (P < .0001) and level of consciousness (95.4%) presented the highest nonapproval rates. CONCLUSIONS Anesthetics and general anesthesia delayed protocol approval; however, after 30 minutes, 75.4% of patients had been approved. Level of consciousness was the main criterion of disapproval. The protocol identified crucial clinical conditions that made it impossible for the patient to receive thirst relief strategies and demonstrated that thirst can be satiated precociously with safety.
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Serato VM, Fonseca LF, Birolim MM, Rossetto EG, Mai LD, Garcia AKA. Package of menthol measures for thirst relief: a randomized clinical study. Rev Bras Enferm 2019; 72:600-608. [DOI: 10.1590/0034-7167-2018-0057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/15/2019] [Indexed: 03/19/2023] Open
Abstract
ABSTRACT Objective: To evaluate the effectiveness of the menthol package (lip hydration and ice popsicles) compared to a package of non-menthol measures (lip hydration and ice popsicles) as a way to relieve thirst in patients in the Anesthetic Recovery Room. Method: Randomized and parallel trial study, with 120 patients randomized patients in an experimental group - menthol measurements (n=59) and control group - measures without menthol (n = 61). Results: There was a significant (p<0.05) decrease in intensity, hydration, dryness and taste in the oral cavity between the three moments of assessment/intervention in the two groups. The difference was significant in the experimental group for thirst intensity at the second assessment/intervention point (p<0.05) after a single administration of the menthol package. Conclusion: There was a reduction in thirst intensity in both groups. Patients who received menthol packages showed a significant decrease in intensity after a single evaluation/intervention time. NCT: 02869139.
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Oller GASADO, Oliveira MPD, Cesarino CB, Teixeira CRDS, Costa JACD, Kusumota L. Clinical trial for the control of water intake of patients undergoing hemodialysis treatment. Rev Lat Am Enfermagem 2018; 26:e3091. [PMID: 30517579 PMCID: PMC6280168 DOI: 10.1590/1518-8345.2694.3091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 09/17/2018] [Indexed: 11/22/2022] Open
Abstract
Objective: to analyze the impact of an educational and motivational intervention for
patients with a chronic kidney disease, undergoing hemodialysis treatment,
on the control of fluid intake during interdialytic periods. Method: a quasi-experimental, non-randomized clinical trial with patients from a
Nephrological Unit of the State of São Paulo. Participants were included in
two groups: Control Group with 106 patients and Intervention Group with 86
patients, totaling 192 participants. The used intervention was an
educational and motivational video to control liquid intake, based on the
Bandura’s Theory. The measure of control of water intake was the percentage
of lost weight, also considered the variable outcome of the research. For
the data analysis, descriptive analyses and regression analysis of the
Inflated Beta Model were used. Results: patients who participated in the intervention had a decrease in the pattern
of weight gain in interdialytic periods, with a 3.54 times more chance of
reaching the goal of 100% of weight loss when compared to participants from
the control group. Conclusion: the educational and motivational intervention was effective in reducing the
percentage of weight loss in patients undergoing hemodialysis. Brazilian
Clinical Trials Registry (ReBEC) under the opinion RBR-4XYTP6.
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Affiliation(s)
| | - Marília Pilotto de Oliveira
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
| | - Cláudia Bernardi Cesarino
- Faculdade de Medicina de São José do Rio Preto, Departamento de Enfermagem Geral, São José do Rio Preto, SP, Brazil
| | - Carla Regina de Souza Teixeira
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
| | | | - Luciana Kusumota
- Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil
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do Nascimento LA, Fonseca LF, dos Santos CB. Inter-rater Reliability Testing of the Safety Protocol for Thirst Management. J Perianesth Nurs 2018; 33:527-536. [DOI: 10.1016/j.jopan.2016.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 07/07/2016] [Accepted: 07/25/2016] [Indexed: 10/19/2022]
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Pierotti I, Fracarolli IFL, Fonseca LF, Aroni P. Evaluation of the intensity and discomfort of perioperative thirst. ESCOLA ANNA NERY 2018. [DOI: 10.1590/2177-9465-ean-2017-0375] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
Abstract Objective: To evaluate the intensity and discomfort of perioperative thirst and related factors during anesthesia recovery. Method: This is a quantitative, cross-sectional, descriptive study. Results: Of the 203 participants, 182 (89.6%) reported they were thirsty. The mean intensity of thirst was 6.9 measured using a verbal numerical scale of 0 to 10 and discomfort was 7.3 on a scale of 0 to 14. All attributes evaluated by the scale were cited including dry mouth and desire to drink water (87.3%), dry lips (79.1%), thick tongue feeling (43.4%), thick saliva (56.5%), dry throat (75.2%) and bad taste in the mouth (63.1%). There was a positive correlation between the intensity of thirst and discomfort assessed by the scale (Spearman coefficient: 0.474; p-value: <0.05). No correlation was found between age, length of fasting and use of opioids with the intensity of thirst and discomfort. Conclusion and implication in the clinical practice: Discomfort arising from the attributes of thirst is evidenced as the intensity of thirst increases.
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Efficacy of an Ice Popsicle on Thirst Management in the Immediate Postoperative Period: A Randomized Clinical Trial. J Perianesth Nurs 2018; 33:153-161. [DOI: 10.1016/j.jopan.2016.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 03/12/2016] [Accepted: 03/20/2016] [Indexed: 11/19/2022]
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Armstrong LE, Johnson EC, Bergeron MF. REBUTTAL from "No". Wilderness Environ Med 2017; 27:200-2. [PMID: 27291702 DOI: 10.1016/j.wem.2016.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Lawrence E Armstrong
- Department of Kinesiology, Human Performance Laboratory, University of Connecticut, Storrs, CT.
| | - Evan C Johnson
- Division of Kinesiology and Health, Human Integrated Physiology Laboratory, University of Wyoming, Laramie, WY
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22
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van Belzen L, Postma E, Boesveldt S. How to quench your thirst. The effect of water-based products varying in temperature and texture, flavour, and sugar content on thirst. Physiol Behav 2017; 180:45-52. [DOI: 10.1016/j.physbeh.2017.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 06/16/2017] [Accepted: 08/11/2017] [Indexed: 10/19/2022]
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Martins PR, Fonseca LF, Rossetto EG. Developing and validating the Perioperative Thirst Discomfort Scale. Rev Esc Enferm USP 2017; 51:e03240. [DOI: 10.1590/s1980-220x2016029003240] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 03/21/2017] [Indexed: 11/22/2022] Open
Abstract
Abstract OBJECTIVE Developing and validating a scale to assess perioperative thirst discomfort. METHOD A methodological research conducted in 2014 and 2015 at the surgical center of a public hospital in the north of Paraná, Brazil. The scale was developed after literature review, followed by face and content validation, and reliability assessment through its internal consistency and inter-observer equivalence. RESULTS Seven items make up the scale: dry mouth; dry lips; thick tongue; thick saliva; dry throat, bad taste and desire to drink water. The content validity index for attributes and items was 0.98, and the reliability index was 1 for the scale attributes and items. Internal consistency assessed by Cronbach's alpha was 0.91 and inter-rater equivalence was 1, as measured by weighted kappa coefficient. CONCLUSION ThePerioperative Thirst Discomfort Scaleshowed high content and reliability indexes.
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Peyrot des Gachons C, Avrillier J, Gleason M, Algarra L, Zhang S, Mura E, Nagai H, Breslin PAS. Oral Cooling and Carbonation Increase the Perception of Drinking and Thirst Quenching in Thirsty Adults. PLoS One 2016; 11:e0162261. [PMID: 27685093 PMCID: PMC5042416 DOI: 10.1371/journal.pone.0162261] [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: 01/11/2016] [Accepted: 08/21/2016] [Indexed: 11/18/2022] Open
Abstract
Fluid ingestion is necessary for life, and thirst sensations are a prime motivator to drink. There is evidence of the influence of oropharyngeal stimulation on thirst and water intake in both animals and humans, but how those oral sensory cues impact thirst and ultimately the amount of liquid ingested is not well understood. We investigated which sensory trait(s) of a beverage influence the thirst quenching efficacy of ingested liquids and the perceived amount ingested. We deprived healthy individuals of liquid and food overnight (> 12 hours) to make them thirsty. After asking them to drink a fixed volume (400 mL) of an experimental beverage presenting one or two specific sensory traits, we determined the volume ingested of additional plain, 'still', room temperature water to assess their residual thirst and, by extension, the thirst-quenching properties of the experimental beverage. In a second study, participants were asked to drink the experimental beverages from an opaque container through a straw and estimate the volume ingested. We found that among several oro-sensory traits, the perceptions of coldness, induced either by cold water (thermally) or by l-menthol (chemically), and the feeling of oral carbonation, strongly enhance the thirst quenching properties of a beverage in water-deprived humans (additional water intake after the 400 ml experimental beverage was reduced by up to 50%). When blinded to the volume of liquid consumed, individual's estimation of ingested volume is increased (~22%) by perceived oral cold and carbonation, raising the idea that cold and perhaps CO2 induced-irritation sensations are included in how we normally encode water in the mouth and how we estimate the quantity of volume swallowed. These findings have implications for addressing inadequate hydration state in populations such as the elderly.
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Affiliation(s)
| | - Julie Avrillier
- Monell Chemical Senses Center, Philadelphia, PA, United States of America
- AgroSup Dijon Institut National Superieur, Dijon, France
| | - Michael Gleason
- Monell Chemical Senses Center, Philadelphia, PA, United States of America
| | - Laure Algarra
- Monell Chemical Senses Center, Philadelphia, PA, United States of America
- AgroParisTech Paris, Paris, France
| | - Siyu Zhang
- Monell Chemical Senses Center, Philadelphia, PA, United States of America
| | - Emi Mura
- Suntory Global Innovation Center Limited, Osaka, Japan
| | - Hajime Nagai
- Suntory Global Innovation Center Limited, Osaka, Japan
| | - Paul A. S. Breslin
- Monell Chemical Senses Center, Philadelphia, PA, United States of America
- Rutgers University Department of Nutritional Sciences, New Brunswick, NJ, United States of America
- * E-mail:
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Bridges E, McNeill M, Munro N. Research in Review: Driving Critical Care Practice Change. Am J Crit Care 2016; 25:76-84. [PMID: 26724298 DOI: 10.4037/ajcc2016564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
During the past year, studies were published that will lead to practice change, address challenges at the bedside, and introduce new care strategies. This article summarizes some of this important work and considers it in the context of previous research and practice. Examples of research-based practice changes include the performance and assessment of septic shock resuscitation, and the integration of tourniquets and massive transfusions in civilian trauma. Care challenges addressed include ethical considerations in light of the Ebola epidemic, infection prevention associated with chlorhexidine bathing, bedside alarm management, evidence to enhance moral courage, and interventions to mitigate thirst in critically ill patients. Research that portends future care includes a discussion of fecal microbiota transplant for patients with refractory infection with refractory infection with Clostridium difficile.
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Affiliation(s)
- Elizabeth Bridges
- Elizabeth Bridges is a clinical nurse researcher and associate professor at the University of Washington Medical Center/School of Nursing, Seattle, Washington. Margaret McNeill is a clinical nurse specialist, perianesthesia, Department of Professional and Clinical Development, Frederick Regional Health System, Frederick, Maryland. Nancy Munro is senior acute care nurse practitioner, Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
| | - Margaret McNeill
- Elizabeth Bridges is a clinical nurse researcher and associate professor at the University of Washington Medical Center/School of Nursing, Seattle, Washington. Margaret McNeill is a clinical nurse specialist, perianesthesia, Department of Professional and Clinical Development, Frederick Regional Health System, Frederick, Maryland. Nancy Munro is senior acute care nurse practitioner, Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
| | - Nancy Munro
- Elizabeth Bridges is a clinical nurse researcher and associate professor at the University of Washington Medical Center/School of Nursing, Seattle, Washington. Margaret McNeill is a clinical nurse specialist, perianesthesia, Department of Professional and Clinical Development, Frederick Regional Health System, Frederick, Maryland. Nancy Munro is senior acute care nurse practitioner, Critical Care Medicine Department, National Institutes of Health, Bethesda, Maryland
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