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Exertion-related dehydration and rehydration therapy

Question Type:
Intervention
Full Question:
Among adults and children with exertion-related dehydration (P), does drinking oral carbohydrate-electrolyte liquids (I), compared with drinking water (C), change Volume/hydration status, vital signs, development of hyperthermia, development of hyponatremia, need for advanced medical care, blood glucose, patient satisfaction (O)?
Consensus on Science:
After the application of inclusion and exclusion criteria to the 1751 initial citations, a total of 12 studies were included. A summary of the evidence from these 12 studies is provided (Table 3).12% CE Solution (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Osterberg 2010, 245) with 30 subjects showing a benefit with the use of CE solution, with increased fluid retention (%) at 2 hours after exercise (MD, 16.1; 95% CI, 7.45–24.75).We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, and development of hyponatremia, or the important outcomes of blood glucose, need for advanced medical care, and patient satisfaction.5% to 8% CE Solution (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 8 studies including 204 subjects showing an overall benefit to 5% to 8% CE solution compared with water in 10 of 15 outcomes, and 5 of 15 showing no difference:• Very-low-quality evidence (downgraded for imprecision) from 1 observational study(Gonzalez-Alonso 1992, 399) with 38 subjects showing at 2 hours after hydration no difference for body weight loss (kg) with CE solution compared with water, a benefit with CE solution with increased rehydration (%) (MD, 8; 95% CI, 6.09–9.91), and a benefit with CE solution for increased blood volume response (%) (MD, 2.8; 95% CI, 2.26–3.34).• Moderate-quality evidence (downgraded for imprecision) from 1 RCT(Wong 2000, 375) with 18 subjects showing no benefit for CE solution compared with water for rehydration (%) at 4 hours after hydration (MD, −1.6; 95% CI, −11.12 to 7.92).• Very-low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Osterberg 2010, 245; Kalman 2012, 1) with 54 subjects showing no difference in fluid retention (%) at 2 hours after hydration for CE solution compared with water; low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Chang 2010, 3220; Kalman 2012, 1) with 44 subjects showing a benefit of CE solution for increased fluid retention (%) at 3 hours (MD, 15.6; 95% CI, 12.44–18.8); very-low-quality evidence (downgraded for imprecision) from 1 observational study(Seifert 2006, 420) with 26 subjects showing a benefit with CE solution for increased fluid retention (%) at 3 hours (MD, 21.7; 95% CI, 9.89–33.51); very-low-quality evidence (downgraded for imprecision) from 1 observational study(Wong 2011, 300) with 26 subjects showing a benefit with CE solution for increased fluid retention (%) at 4 hours (MD, 22; 95% CI, 9.6–34.4); low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Shirreffs 2007, 173) with 22 subjects showing no difference in fluid retention (%) at 4 hours.• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Chang 2010, 3220) with 20 subjects showing a benefit with CE solution compared with water with decreased mean urine volume by weight (g) between 1 and 2 hours after hydration (MD, −175; 95% CI, −206.37 to −143.63) and a benefit of CE solution with decreased mean urine volume between 2 and 3 hours after hydration (MD, −41; 95% CI, −64.27 to −17.73); very-low-quality evidence (downgraded for imprecision) from 1 observational study(Gonzalez-Alonso 1992, 399) with 38 subjects showing at 2 hours after hydration a benefit with CE solution with decreased mean urine volume (mL) (MD, −160; 95% CI, −198.15 to −121.85); very-low-quality evidence (downgraded for imprecision) from 1 observational study(Seifert 2006, 420) with 26 subjects showing a benefit with CE solution with decreased mean urine volume (mL) at 3 hours after hydration (MD, −465.3; 95% CI, −700.73 to −229.87); low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Shirreffs 2007, 173) with 22 subjects showing no difference for mean urine volume (mL) at 4 hours after hydration; and very-low-quality evidence (downgraded for imprecision) from 1 observational study(Wong 2011, 300) with 26 subjects showing a benefit with CE solution with decreased mean urine volume (mL) at 4 hours after hydration (MD, −277; 95% CI, −458.26 to −95.74).• Very-low-quality evidence (downgraded for imprecision) from 1 observational study(Seifert 2006, 420) with 26 subjects showing no difference in plasma volume change (%) at 3 hours after hydration with CE solution; 1 observational study of very-low-quality evidence(Wong 2011, 300) (downgraded for imprecision) with 26 subjects showing a benefit with CE solution with increased plasma volume change (%) at 4 hours (MD, 11; 95% CI, 9.42–12.58).For the critical outcome of vital signs, we identified the following:• Very-low-quality evidence (downgraded for imprecision) from 1 observational study(Wong 2011, 300) with 26 subjects showing no significant difference for HR (BPM) at 1 hour after hydration and at 3 hours after hydration with CE solution. • Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Hostler 2010, 194) with 36 subjects showing no difference in HR (BPM) 20 minutes after hydration or respiratory rate (BPM) 20 minutes after hydration with CE solution.• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 subjects showing no benefit with CE solution for HR (BPM) at 3 hours after hydration (MD, 7; 95% CI, −0.02 to 14.02).For the critical outcome of development of hyperthermia, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Hostler 2010, 194) with 36 subjects showing no difference in core temperature (°C) after hydration with CE solution compared with water.For the critical outcome of development of hyponatremia (a potential complication of endurance exercise), we identified moderate-quality evidence (downgraded for imprecision) from 1 RCT(Wong 2000, 375) with 18 subjects showing an increased serum sodium (mmol/L) at 2 hours after hydration (MD, 3; 95% CI, 2.08–3.92), at 3 hours (MD, 3; 95% CI, 2.08–3.92), and at 4 hours after hydration (MD, 4; 95% CI, 3.08–4.92) with CE solution compared with water.We did not identify any evidence to address the important outcome of need for advanced medical care. For the important outcome of patient satisfaction, we identified the following:• Very-low-quality evidence (downgraded for imprecision) from 1 observational study(Wong 2000, 375) with 26 subjects showing no difference in abdominal discomfort ratings (1–10) with CE solution compared with water at 2, 3, and 4 hours after hydration, and no difference in stomach fullness ratings (1–10) at 2, 3, or 4 hours after hydration.• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 participants showing no difference in stomach upset ratings (1–5) at 2 or 3 hours after hydration with CE solution compared with water.We did not identify any evidence to address the important outcome of blood glucose.3% to 4% CE Solution (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified the following:• Low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Saat 2002, 93; Ismail 2007, 769) with 36 subjects showing no difference in the rehydration index for CE solution compared with water.• Very-low-quality evidence (downgraded for risk of bias and imprecision) from 3 RCTs(Saat 2002, 93; Ismail 2007, 769; Osterberg 2010, 245) with 66 subjects showing a benefit with CE solution with increased fluid retention (%) at 2 hours after hydration (MD, 8.97; 95% CI, 7.54–10.4).• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Ismail 2007, 769) with 20 subjects showing a benefit of CE solution with decreased cumulative urine output (mL) at 2 hours into the hydration period (MD, −174.5; 95% CI, −220.89 to −128.11).For the important outcome of patient satisfaction, we identified the following:• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Ismail 2007, 769) with 20 subjects showing no difference for nausea scores (1–5) at 90 minutes after hydration with CE solution, and low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Saat 2002, 93; Ismail 2007, 769) with 36 subjects showing no difference for nausea scores (1–5) at 2 hours for CE solution compared with water.• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Ismail 2007, 769) with 20 subjects showing no difference for stomach upset scores (1–5) at 90 minutes after hydration with CE solution compared with water, and low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Saat 2002, 93; Ismail 2007, 769) with 36 subjects showing a benefit with CE solution with a decrease in stomach upset scores (1–5) at 2 hours after hydration (MD, −0.3; 95% CI, −0.45 to 0.16).We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, and development of hyponatremia, or the important outcomes of blood glucose and need for advanced medical care.Coconut Water (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified the following:• Low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Saat 2002, 93; Ismail 2007, 769) with 36 subjects showing no difference in rehydration index for coconut water compared with water. • Very-low-quality evidence (downgraded for risk of bias and imprecision) from 3 RCTs(Saat 2002, 93; Ismail 2007, 769; Kalman 2012, 1) with 60 subjects showing a benefit with coconut water with increased fluid retention (%) at 2 hours after hydration (MD, 5.81; 95% CI, 4.35–7.27), and very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 subjects showing no difference in fluid retention (%) at 3 hours after hydration with coconut water compared with water. • Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Ismail 2007, 769) with 20 subjects showing a benefit with coconut water with decreased cumulative urine output (mL) at 2 hours into the hydration period (MD, −76.9; 95% CI, −120.34 to −33.46) compared with water.For the important outcome of patient satisfaction, we identified the following:• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Ismail 2007, 769) with 20 subjects showing no difference for nausea scores (1–5) with coconut water compared with water at 90 minutes after hydration and at 2 hours.• Low-quality evidence (downgraded for risk of bias and imprecision) from 1 randomized trial(Ismail 2007, 769) with 20 subjects showing a benefit with coconut water with a decrease in stomach upset scores (1–5) at 90 minutes after hydration (MD, −0.4; 95% CI, −0.54 to −0.26), very-low-quality evidence (downgraded for risk of bias and imprecision) from 2 RCTs(Ismail 2007, 769; Kalman 2012, 1) with 44 subjects showing benefit with coconut water with a decrease in stomach upset scores (1–5) at 2 hours after hydration (MD, −0.41; 95% CI, −0.55 to −0.28), and very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 subjects showing no benefit with coconut water with an increase in stomach upset scores (1–5) at 3 hours after hydration with the coconut water compared with water (MD, 1.84; 95% CI, 1.08–2.6).We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, or development of hyponatremia, or the important outcomes of blood glucose or need for advanced medical care.3% Sodium Plus Coconut Water (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Ismail 2007, 769) with 20 subjects showing a benefit with 3% sodium plus coconut water compared with water, with a decreased rehydration index (MD, −0.7; 95% CI, −0.81 to −0.59), a benefit with 3% sodium plus coconut water with increased retained fluid (%) at 2 hours after hydration (MD, 10.5; 95% CI, 9.09–11.91), and a benefit with 3% sodium plus coconut water with decreased urine volume (mL) at 2 hours after hydration (MD, −150.3; 95% CI, −187.39 to −113.21).For the important outcome of patient satisfaction, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 randomized trial(Ismail 2007, 769) with 20 subjects showing a benefit with 3% sodium plus coconut water compared with water, with less nausea (1–5) at 90 minutes after hydration (MD, −0.2; 95% CI, −0.38 to −0.02).We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, and development of hyponatremia, or the important outcomes of blood glucose or need for advanced medical care.Coconut Water From Concentrate (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 subjects showing no difference in mean fluid retention at 120 minutes after exercise (MD, 10.7; 95% CI, −6.39 to 27.79) for coconut water from concentrate compared with water, but higher mean fluid retention with coconut water at 180 minutes after exercise (MD, 17; 95% CI, 0.86–33.14).For the critical outcome of vital signs, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 subjects showing no difference in mean HR (BPM) at 180 minutes after exercise with coconut water from concentrate compared with water.For the important outcome of patient satisfaction, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Kalman 2012, 1) with 24 subjects showing no difference in mean stomach upset score (1–5) for coconut water from concentrate compared with water at 120 minutes (MD, 1.84; 95% CI, 0.91–2.77) and at 180 minutes (MD, 1.47; 95% CI, 0.6–2.34).We did not identify any evidence to address the critical outcomes of development of hyperthermia or development of hyponatremia, or the important outcomes of blood glucose or need for advanced medical care.Green Tea–Based 4.2% CE Solution (I) Compared With Water (C)For the important outcome of blood glucose, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Miccheli 2009, 553) with 48 subjects showing that a green tea–based 4.2% CE solution was associated with increased mean glucose (mg/dL) at 2 hours after hydration compared with water (MD, 6.9; 95% CI, 1.59–12.21).We did not identify any evidence to address the critical outcomes of volume/hydration status, vital signs, development of hyperthermia, and development of hyponatremia, or the important outcomes of need for advanced medical care and patient satisfaction.Lemon Tea–Based 12% CE (t-CE) Solution (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified of very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Wong 2011, 300) with 26 subjects showing no difference in mean retained fluid (%) at 4 hours after hydration (MD, 6; 95% CI, −5.15 to 17.15) with t-CE solution compared with water and no difference in mean urine volume (mL) at 4 hours after hydration.For the critical outcome of vital signs, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Wong 2011, 300) with 26 subjects showing no difference in mean HR (BPM) at 60 minutes after hydration with t-CE solution compared with water.For the important outcome of patient satisfaction, we identified very-low-quality evidence (downgraded for risk of bias and imprecision) from 1 observational study(Wong 2011, 300) with 26 subjects showing no difference in mean abdominal discomfort scores (1–10) at 120 minutes after hydration with t-CE, no benefit with t-CE with an increase in abdominal discomfort scores at 180 minutes (MD, 1.3; 95% CI, 0.69–1.91), and no benefit with t-CE compared with water with an increase in abdominal discomfort at 240 minutes; also, there was no difference for mean stomach fullness scores (1–10) with t-CE solution at 120 minutes after hydration, and no significant difference for mean stomach fullness scores with t-CE solution at 180 minutes or at 240 minutes as compared with water.We did not identify any evidence to address the critical outcome of development of hyperthermia and development of hyponatremia, or the important outcome of blood glucose and need for advanced medical care.Chinese Tea Plus Caffeine (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Chang 2010, 3220) with 20 subjects showing no difference with Chinese tea plus caffeine compared with water in mean total body water loss (%), no difference in mean fluid retention (%) at 3 hours after hydration, and no significant difference in mean urine volume by weight (g) between 60 and 120 minutes or between 120 and 180 minutes after hydration.We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, or development of hyponatremia, or the important outcomes of blood glucose, need for advanced medical care, or patient satisfaction.Milk (2% Fat) (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Shirreffs 2007, 173) with 22 subjects showing a benefit with milk (2% fat) compared with water at 4 hours after hydration for fluid retention (%) (MD, 33; 95% CI, 24.64–41.36) and for urine volume (mL) (MD, −594; 95% CI, −742.34 to −445.66).We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, or development of hyponatremia, or the important outcomes of blood glucose, need for advanced medical care or patient satisfaction.Milk (2% Fat) Plus High Sodium (Na+) and Potassium (K+) Concentration (I) Compared With Water (C)For the critical outcome of volume/hydration status, we identified low-quality evidence (downgraded for risk of bias and imprecision) from 1 RCT(Shirreffs 2007, 173) with 22 subjects showing a benefit with milk (2% fat) with high Na+/K+ concentration compared with water at 4 hours after hydration for fluid retention (%) (MD, 36; 95% CI, 29.64–42.36) and benefit with urine volume (mL) (MD, −655; 95% CI, −773.26 to −536.74). We recognize that this beverage is not a standard commercial product.We did not identify any evidence to address the critical outcomes of vital signs, development of hyperthermia, or development of hyponatremia, or the important outcomes of blood glucose, need for advanced medical care or patient satisfaction.
Treatment Recommendation:
We suggest that first aid providers use 3% to 8% CE drinks for treating exertion-related dehydration. If 3% to 8% CE drinks are not available or not tolerated, alternative beverages for rehydration include water, 12% CE solution, coconut water, 2% milk, tea, tea-CE, or caffeinated tea beverages (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force InsightsIn making this recommendation, we recognize that first aid providers are commonly recruited to assist at first aid stations located at sporting and challenge events and that exercise-induced dehydration is a common problem. It may not be possible to determine the exact quantity or percent of fluid loss in the first aid setting. Public comment was made about the potential mortality associated with ingestion of water only during ultramarathons. The reviewers for this PICO question specifically looked at sodium levels reported after rehydration in the included studies and agreed that oral rehydration with CE liquids may assist in preventing hyponatremia, although this review did not specifically address exercise-associated hyponatremia. In addition, all included trials conducted exercise in a controlled environment and time period. Extreme events such as ultramarathons were not included in the evidence evaluation.
CoSTR Attachments:
Data collection form 1_20_15_n.xlsx    
Dehydration GRADE Evidence Profile 1_10_2015_n.docx    

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