Worksheet No. FA-1705A Page 1 of 7

Worksheet No. FA-1705A Page 1 of 7 WORKSHEET for Evidence-Based Review of Science for First Aid Worksheet author(s) Susan W. Yeargin, PhD, ATC Date Submitted for review: Initial: 11/30/09 Clinical question. General: In hypohydrated individuals, do carbohydrate-electrolyte drinks compared to water rehydrate an individual? PICO Format: In hypohydrated individuals (P) does providing fluids (I) as compared to providing no fluids (C) decrease symptoms (O)? In hypohydrated individuals (P) does a carbohydrate-electrolyte beverage (I) compared to water (C) rehydrate individuals (O)? Is this question addressing an intervention/therapy, prognosis or diagnosis? Intervention State if this is a proposed new topic or revision of existing worksheet: New Topic Conflict of interest specific to this question Do any of the authors listed above have conflict of interest disclosures relevant to this worksheet? Yes, Intellectual interest Search strategy (including electronic databases searched). Cochrane Reviews, DARE, and CENTRAL: hypohydrated OR dehydrated OR fluid loss AND treatment OR rehydration OR drinking OR fluid replacement as text words in abstract field. Additional terms used were water OR carbohydrate electrolyte beverage OR sport drink Medline, PubMed, PubMed Central, CINAHL, and Pre CINAHL: same search terms as above MESH Terms: Fluid Therapy*/adverse effects Gastroenteritis/*therapy Rehydration Solutions/*standards Rehydration Solutions/*therapeutic use Rest/*physiology Body Fluids/physiology Beverages* Drinking Behavior* Water-Electrolyte Balance* Dehydration/*therapy Dietary Carbohydrates/*administration & dosage Glucose/*administration & dosage Administration, Oral State inclusion and exclusion criteria Inclusionary items: dehydration, hypohydration, or fluid loss due to exercise, being in warm environments, and common illnesses (gastroenteritis). Exclusionary items: special populations and diseases (i.e. cystic fibrosis, multiple sclerosis, musculoskeletal diseases, cholera, malaria, cancer), animals, pregnancy, infants, and beverages not available to the lay rescuer Number of articles/sources meeting criteria for further review: 20 articles currently meet criteria for review. Of these, 3 were LOE 1, 12 were LOE 2, and 5 was LOE 3.

Worksheet No. FA-1705A Page 2 of 7 Summary of evidence Evidence Supporting Clinical Question Good Fair Castellani, 1997 AB Kenefick, 2000 AB Kenefick, 2007 AB Kenefick, 2006 AB Maresh 2001, ABC Riebe, 1997 AB Maughan, 1995 AB Rao, 2006 ABC Shirreffs, 1998 ABD Nose, 1988 ABD Shirreffs, 1996 AB Mitchell, 2000 AB Maughan, 1994 AB Armstrong 1997, AD Greenleaf, 1998 ABCD Evans b, 2009 ABC Shirreffs, 2007 ABCD Merson, 2008 AB Poor 1 2 3 4 5 Level of evidence A = Successful rehydration via oral solution B = Successful rehydration via NaCl beverage C = Successful rehydration via Carbohydrate beverage D= Successful rehydration via water

Worksheet No. FA-1705A Page 3 of 7 Evidence Neutral to Clinical question Good Fair Wong, 2000 ABC Gonzalez, 1992 ABCD Evans, 2009 ABC Poor 1 2 3 4 5 Level of evidence A = Successful rehydration via oral solution B = Successful rehydration via NaCl beverage C = Successful rehydration via Carbohydrate beverage D= Successful rehydration via water Evidence Opposing Clinical Question Good Fair Poor 1 2 3 4 5 Level of evidence A = Successful rehydration via oral solution B = Successful rehydration via NaCl beverage C = Successful rehydration via Carbohydrate beverage D= Successful rehydration via water

Worksheet No. FA-1705A Page 4 of 7 REVIEWER S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK (please include implementation considerations including at a minimum training, environment and availability: There is a solid foundation of research exploring sports drinks or carbohydrate electrolyte beverages (CEB) in the literature but not as many that actually compare CEB directly to water. Instead the research focuses upon different formulations of carbohydrate and NaCl to optimize rehydration. Measures of successful rehydration were: increased fluid intake, plasma volume expansion, decreased urine output (conservation of fluids), and return to baseline body mass. Overall, the research showed optimal successful rehydration in CEBs with higher levels of carbohydrate and NaCl- which can be found in some commercially made CEBs. The key component of the CEB being the NaCl level due to the simple fact that water follows NaCl. Therefore, if you increase NaCl, the more water will be retained in the body. Studies that have compared CEB directly to water still support the use of water as a rehydration beverage however have shown benefits to using the CEB over water. Ingestion of plain water can result in the decrease in plasma NaCl and therefore osmolality. These changes result in reducing voluntary fluid intake and stimulate increased urine output- both of which will delay complete rehydration(shiteffs 1998;868, Nose 1988;332, Gonzalez-Alonso1992;399, Greenleaf 1998; 837, Shirreffs 2007;1899). With CEBs, the amount of NaCl is inversely related to urine output- the more NaCl the less urine output(shirreffs 1998, Maughan 1995, Merson 2008). This means more of the CEB is retained in the body to help return the individual to euhydration. (Of note: sodas, juices, and alcohol contain no NaCl and therefore should not be used for rehydration as well as for other reasons). Research shows that carbohydrate by itself doesn t necessarily optimize rehydration but instead replaces glucose levels within the body. However, the carbohydrate does make the NaCl more palatable and increases voluntary fluid intake (Greenleaf 1998, Evans 2009 Shirreffs 2007). Little is known about the role of other electrolytes in the rehydration process and therefore may not be a concern to the lay rescuer till more is known. A significant amount of research has been done on oral rehydration versus intravenous administration (Castellani 1997, Kenefick 2000,, Kenefick 1899, Kenefick 2006, Riebe 1997). Even though a lay rescuer cannot perform IV administration, this research supports encouraging the lay rescuer to use oral rehydration with treating someone with dehydration unless the patient cannot tolerate it (vomiting, psychological reasons). Reasons of support for oral rehydration are: - Plasma volume changes are the same for IV and oral by about the 15 minute mark of rehydration - Plasma osmolality is the same throughout rehydration for IV & oral - Skin blood flow is the same in oral and IV - SV, cardiac output, HR are the same in oral & IV - Skin temperature and rectal temperature are similar in oral as compared to IV - Similar fluid regulatory hormone responses - Thirst, Thermal and RPE perceptions are lower for oral as compared to IV Another aspect of treating a dehydrated individual is the amount of fluid the lay rescuer should provide. Research suggests that the amount should exceed how much the individual lost since urine losses, respiratory losses, and possible sweating will allow additional fluid losses even after rehydration has begun (Shirreffs 1996, Mitchell 2000, Wong 2000, Evans 2009, Merson2008, Shirreffs 2007). Research revealed that hypohydrated individuals did not restore their hydration status when fluid consumed only matched their fluid loss (no matter the electrolyte content of the beverage). However, when 150% of their fluid losses were consumed with a high NaCl content, their hydration status returned to euhydration. The lay rescuer will not be able to determine how much their patient has lost, nor be able to calculate what 150% of their losses would be, however the lay rescuer can be taught to encourage the patient to consume a good amount of fluids by having the patient drink more than just sipping while avoiding a sloshy feeling. Once the patient has an urge to urinate, it can be assumed that they have reached a good point in the rehydration process. Acknowledgements:

Worksheet No. FA-1705A Page 5 of 7 Castellani, J. W., C. M. Maresh, et al. (1997). "Intravenous vs. oral rehydration: effects on subsequent exercise-heat stress." Journal of Applied Physiology (Bethesda, Md : 1985) 82(3): 799-806. Solid research design. Results suggest when treating with a NaCl solution, that there is no benefit of choosing intravenous fluids over oral rehydration. Evans, G. H., S. M. Shirreffs, et al. (2009). "Post exercise rehydration in man: the effects of carbohydrate content and osmolality of drinks ingested ad libitum." Applied Physiology, Nutrition, And Metabolism = Physiologie Appliquà e, Nutrition Et Mà tabolisme 34(4): 785-793. Research design is solid. Dehydration level and subject number slightly low. Results suggest carbohydrate itself doesn't help enhance rehydration. However each of CEB did successfully rehydrate each subject. Evans, G. H., S. M. Shirreffs, et al. (2009). "Post exercise rehydration in man: the effects of osmolality and carbohydrate content of ingested drinks." Nutrition (Burbank, Los Angeles County, Calif.) 25(9): 905-913. Research design is solid. Dehydration and subject numbers slightly low. Results suggest that a CEB rehydrates successfully and possibly better than low osmo solutions. Gonzà lez-alonso, J., C. L. Heaps, et al. (1992). "Rehydration after exercise with common beverages and water." International Journal Of Sports Medicine 13(5): 399-406. Good research design. Results suggest that both water and CEB rehydrate a person successfully as compared to diet cola. Greenleaf, J. E., C. G. Jackson, et al. (1998). "Plasma volume expansion with oral fluids in hypohydrated men at rest and during exercise." Aviation, Space, And Environmental Medicine 69(9): 837-844. Research design is solid. Results suggest that CEB increased PV more than water indicating CEB a better rehydration beverage. Kenefick, R. W., C. M. Maresh, et al. (2000). "Plasma vasopressin and aldosterone responses to oral and intravenous saline rehydration." Journal Of Applied Physiology (Bethesda, Md.: 1985) 89(6): 2117-2122. Solid research design. Results support that when treating with a NaCl solution there is no difference between intravenous or oral rehydration methods. Kenefick, R. W., C. M. Maresh, et al. (2007). "Rehydration with fluid of varying tonicities: effects on fluid regulatory hormones and exercise performance in the heat." Journal Of Applied Physiology (Bethesda, Md : 1985) 102(5): 1899-905. Solid research design. Results support that when treating with a NaCl solution, there is no difference between intravenous and oral rehydration methods.

Worksheet No. FA-1705A Page 6 of 7 Kenefick, R. W., K. M. O'Moore, et al. (2006). "Rapid IV versus oral rehydration: responses to subsequent exercise heat stress." Medicine And Science In Sports And Exercise 38(12): 2125-31. Solid research design. Results support when using a NaCl solution, there is not a difference between intravenous and oral rehydration methods. Maresh, C. M., J. A. Herrera-Soto, et al. (2001). "Perceptual responses in the heat after brief intravenous versus oral rehydration." Medicine And Science In Sports And Exercise 33(6): 1039-1045. Good research design. Results suggest that the oral rehydration is better than IV at decreasing sensations of thirst. Maughan, R. J. and J. B. Leiper (1995). "Sodium intake and post-exercise rehydration in man." European Journal Of Applied Physiology And Occupational Physiology 71(4): 311-319. A well designed and controlled study. Results suggest that a NaCl beverage, especially higher NaCl content beverages, increases rehydration efforts. Maughan, R. J., J. H. Owen, et al. (1994). "Post-exercise rehydration in man: effects of electrolyte addition to ingested fluids." European Journal Of Applied Physiology And Occupational Physiology 69(3): 209-215. Good research design, small amount of subjects. Results suggest all formulations studied of CEB successfully rehydrated subjects. Merson, S. J., R. J. Maughan, et al. (2008). "Rehydration with drinks differing in sodium concentration and recovery from moderate exercise-induced hypohydration in man." European Journal Of Applied Physiology 103(5): 585-594. Research design is solid. Results suggest that NaCl beverages successfully rehydrate individuals, especially higher NaCl levels. Mitchell, J. B., M. D. Phillips, et al. (2000). "Post exercise rehydration: effect of Na(+) and volume on restoration of fluid spaces and cardiovascular function." Journal Of Applied Physiology (Bethesda, Md.: 1985) 89(4): 1302-1309. Very good research design. All NaCl beverages rehydrated subjects successfully, especially those given in significant volumes. Nose, H., G. W. Mack, et al. (1988). "Involvement of sodium retention hormones during rehydration in humans." Journal Of Applied Physiology (Bethesda, Md.: 1985) 65(1): 332-336.

Worksheet No. FA-1705A Page 7 of 7 Research design is solid. Results suggest NaCl beverage rehydrated better than water in terms of plasma volume restoration. Rao, S. S. C., R. W. Summers, et al. (2006). "Oral rehydration for viral gastroenteritis in adults: a randomized, controlled trial of 3 solutions." JPEN. Journal Of Parenteral And Enteral Nutrition 30(5): 433-439. Well designed and controlled study. Results suggest that the CEB rehydrated successfully. Riebe, D., C. M. Maresh, et al. (1997). "Effects of oral and intravenous rehydration on ratings of perceived exertion and thirst." Medicine And Science In Sports And Exercise 29(1): 117-24. Solid research design. Results suggest that when treating with a NaCl solution, use of oral rehydration may be of benefit to decrease perceptual sensations in the dehydration victim. Shirreffs, S. M., L. F. Aragon-Vargas, et al. (2007). "Rehydration after exercise in the heat: a comparison of 4 commonly used drinks." International Journal Of Sport Nutrition And Exercise Metabolism 17(3): 244-258. Fair research design. Results suggest that the CEB was better compared to water in successful rehydration. Shirreffs, S. M. and R. J. Maughan (1998). "Volume repletion after exercise-induced volume depletion in humans: replacement of water and sodium losses." The American Journal Of Physiology 274(5 Pt 2): F868-75. Research design and data collection methods are solid. Results support treating dehydration and sodium sweat losses with NaCl solutions. Shirreffs, S. M., A. J. Taylor, et al. (1996). "Post-exercise rehydration in man: effects of volume consumed and drink sodium content." Medicine And Science In Sports And Exercise 28(10): 1260-1271. Good research design. Results suggest increased volumes of NaCl beverages have successful rehydration. Wong, S. H., C. Williams, et al. (2000). "Effects of ingesting a large volume of carbohydrateelectrolyte solution on rehydration during recovery and subsequent exercise capacity." International Journal Of Sport Nutrition And Exercise Metabolism 10(4): 375-393. Good research design. Results suggest high volumes of CEB or just a Carbo beverage successfully rehydrate an individual but that the CEB may be better.