Running head: ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES1ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES2

Alcohol Detoxification and Hydration Outcomes

Molly Chaffin

The University of Southern Mississippi

IntroductionConsumption of alcoholic beverages has been seen throughout the ages, beginning somewhere around 1000 A. D. (Rundio, 2013b). Alcohol is produced by fermentation of sugars to produce ethanol. When ethanol is ingested, it is rapidly absorbed in the GI tract and sent to the liver for metabolism by the enzyme alcohol dehydrogenase. This enzyme breaks down alcohol at a set rate per hour depending on the individual; alcohol that is consumed at a greater rate than is broken down results in an increased blood alcohol content, producing various symptoms such as altered mental status, blurred vision, slurred speech, and ataxia (Rundio, 2013b). Alcohol is a commonly used and abused substance in the United States. According to the National Survey on Drug Abuse and Health (NSDAH), over half of Americans (56%) claimed to be current alcohol drinkers; 23.3% of these respondents reported binge drinking, or consuming >5 drinks in one occasion (Substance Abuse and Mental Health Services Administration, 2014). Nearly 10% of adults consume alcohol excessively, and this number nearly doubles in acute care patients (Rundio, 2013a). While moderate alcohol use is not generally associated with negative health outcomes, long-term alcohol abuse can be detrimental to an individuals health. Alcohol abuse can cause significant damage to many systems in the body. Due to the livers large role in alcohol metabolism, liver disease is often seen in chronic alcoholism. Cirrhosis of the liver or fatty liver disease are often results of chronic alcoholism. Physical damage also may occur to the gastrointestinal (GI) system such as inflammation, ulcers, or other GI symptoms such as diarrhea and vomiting. Alcohol abuse can also lead to pancreatitis, heart failure, anemia, various cancers, and nervous system dysfunctions (Rundio, 2013b). In 2005, the National Survey on Drug Abuse and Health found that 18.7 million Americans depended on or abused alcohol (Substance Abuse and Mental Health Services Administration, 2014). Alcohol dependence is characterized by cravings, loss of control, increased tolerance to alcoholic beverages, and withdrawal symptoms after periods of abstinence (Rundio, 2013b). While withdrawal symptoms are rarely seen in the general population, over 80% of individuals admitted for alcohol detoxification exhibit symptoms. These symptoms might include tremors, hallucinations, tachycardia, seizures, fevers, hyperventilation, nausea, vomiting, and electrolyte imbalance, and dehydration (McKeon, Frye, & Delanty, 2008). Due to the severity of these symptoms, alcohol detoxification is a taxing and often dangerous process. Established protocols are required for management of alcohol abuse patients in acute care and rehabilitation facilities. Treatment often involves pharmacological agents such as benzodiazepines to reduce the risk of seizures (McKeon et al., 2008). Benzodiazepines might also be used to reduce delirium tremors, which when left untreated, pose the greatest risk for mortality in alcohol withdrawal syndrome (Maldonado, 2010) Other medications may be used in combination with benzodiazepines to lower heart rate and prevent further cardiac complications such as angina, hypertension, and arrhythmias (McKeon et al., 2008). Other harmful effects of alcohol withdrawal syndrome include nutrient deficiencies and electrolyte imbalances. One common symptom seen in alcoholic patient is thiamin deficiency. Thiamin deficiencies may results from inadequate dietary intake, decreased absorption, or increased excretion due to excessive alcohol intake. Complications of thiamin deficiencies are often difficult to detect, yet complications such as Wernickes encephalopathy can results in further neural complications such as amnesia, confusion, and delirium. Proper replenishment of thiamin stores is necessary to prevent irreversible neural damage and further complications (Maldonado, 2010)Decreased serum sodium levels are also frequently seen in alcoholics, specifically those who consume large amounts of fluids such as beer. Other serum electrolyte levels including potassium, phosphate, and magnesium are also often depressed due to poor nutritional intake and GI symptoms such as vomiting (McKeon et al., 2008). These values must be monitored and corrected along with proper fluid intake to prevent dehydration and worsening of symptoms.Electrolyte and fluid replacement therapy are essential for patients experiencing alcohol withdrawal syndrome; however, electrolyte-supplemented beverages often provide high amounts of sugar and sodium. This form of fluid replacement may not be the most beneficial method for rehydration and electrolyte balance in all patients, especially those with co-morbidities such as diabetes, hypertension, and renal insufficiency. Commercial carbohydrate and electrolyte-enhanced beverages have been shown to be no more effective in improving hydration status than water alone (Miller, Mack, & Knight, 2009). This study found that ingestion of a carbohydrate-containing beverage produced no significant changes in plasma sodium, potassium, magnesium, and calcium one-hour post ingestion. Little other evidence has been published detailing the benefits of these beverages for detoxification or electrolyte balance in general. These results pose the question of whether or not commercial electrolyte-enhanced carbohydrate beverages are beneficial for rehydration of detoxification patients. Despite the lack of evidence in this area, some rehabilitation facilities, such as the Veterans Health Administration (VHA) of Biloxi, use commercial electrolyte-enhanced beverages (specifically Gatorade) to provide fluid and electrolytes to patients undergoing alcohol detoxification (Jami Woodham, personal communication, October 7, 2014). Standard protocol at the VHA requires that detoxification patients receive three quarts of an electrolyte-enhanced carbohydrate beverage each day for the initial three days following admission. This beverage is distributed to all newly admitted patients despite laboratory values or co-morbidities (Jami Woodham, personal communication, October 7, 2014). While this protocol was established in an attempt to deter dehydration and provide adequate electrolyte supplementation, the evidence is not clear as to whether or not this method is more effective (or potentially more harmful) than adequate fluid intake and a standard inpatient diet meeting the recommended dietary intake (RDI). Problems with the current protocol include a lack of nutrition assessments prior to recommendations. Detoxification patients are prescribed low sodium or diabetic diets when certain co-morbidities are presented; however, the high sodium and sugar content of electrolyte beverages are not considered as part of the diet order and therefore not addressed by the dietitian (Jami Woodham, personal communication, October 7, 2013). These nutrients could cause major health risks such as hyperglycemia or increased blood pressure. These beverages also add unnecessary calories when recommended amount of nutrients and electrolytes can be obtained from the standard diet at the VHA (Jami Woodham, personal communication, October 7, 2013). The effectiveness of commercial electrolyte-enhanced beverages has not been proven to improve hydration status more effectively than other fluid replacement of water and diet alone (Miller, Mack, & Knight, 2009). Therefore, research should be conducted to determine if commercial electrolyte-enhanced beverage intake of 96 oz. per day normalizes laboratory markers of serum electrolytes (sodium, potassium, magnesium, and calcium) and improves hydration status (increasing weight and urine output) more effectively than equivalent fluid intake of water, milk, kool-aid, and fruit juice provided with the regular inpatient diet (meeting 80% of all RDIs) for the three days following admission. Study Questions and Objectives Question: Does consumption of 3 quarts per day of commercial electrolyte-enhanced fluid (Gatorade) improve hydration status markers improve hydration status and normalize electrolyte balance (according to laboratory markers of sodium, potassium, calcium, and magnesium) more effectively than the standard inpatient diet with 3 quarts of fluid intake (including water, juice, milk, and kool-aid) during the initial three days of admission for alcohol abuse patients?Objective 1: Determine if changes in hydration status vary (according to changes in weight and urine output) between subjects receiving 3 quarts of Gatorade per day and subjects receiving 3 quarts of fluids (including water, juice, milk, and kool-aid). Objective 2: Determine if laboratory markers of electrolytes (sodium, potassium, calcium, and magnesium) approach normal levels at different rates between the two sample groups during the three days of data collection. Methodology & Procedure The following flow chart illustrates the VHAs current protocol for alcohol detoxification patients. As shown by the flow chart, patients are provided 3 quarts of Gatorade per day regardless of co-morbidities, hydration status, or any other factor. Adequate research has not been conducted to determine if electrolyte replacement beverages such as Gatorade actually aid in fluid and electrolyte balance. The standard protocol may not be the most beneficial to all patients, especially those with comorbidities such as diabetes or hypertension, due to the excess intake of sugar and sodium. This protocol may also not be the best use of funds for the hospital if these beverages do not improve hydration more than the standard diet order and adequate fluid intake.

This randomized-controlled trial will determine the effectiveness of a standard carbohydrate, electrolyte-enhanced beverage (Gatorade) in improving hydration status and electrolyte balance during the initial three days of alcohol detoxification in the VHAs impatient rehabilitation program. This study will include male and female adults (>18 years of age) admitted for alcohol detoxification over a six-month period with the goal of > 50 subjects per sample group. Patients must be newly admitted to the program after the initiation of the study and data collection. Subjects must also be prescribed a regular diet order; individuals with diet orders including NPO, therapeutic diets (including cardiac, low sodium, diabetic, etc.), or orders of additional dietary supplements (such as Boost) may not participate in the study. Individuals with allergies that may further restrict the regular diet (such as lactose intolerance) will also be excluded. Patients transferred from the acute care unit or other detoxification programs may not participate in the study. Subjects with conflicting co-morbidities such as renal insufficiency, hypertension, diabetes, or intractable vomiting or diarrhea will be excluded from the study. Patients who do not complete the initial three days of the program will also be excluded from the final results. Data will be published in the results only when patients consume greater than 50% of the 3-quart recommendation. This will ensure that amount consumed is significant enough to produce results. Participants who do not consume at least 50% (or at least 1.5 quarts) of fluid will not be included in the study results.Following informed consent and agreement to participate in the study, alcohol detoxification patients will be randomly assigned either the Gatorade group or the standard fluid group upon admission. Subjects in the Gatorade group will receive the standard protocol of 3 quarts of Gatorade per day along with regular meal trays (excluding beverages) for the three days immediately following admission; subjects in the standard fluid group will receive 1.5 quarts of water with 2 cups of the standard beverage (orange or grape juice, kool-aid, or 1% milk) on each of the three meal trays per day. Subjects will be instructed to drink to thirst, with encouragement for adequate hydration to quell nausea, headaches, and general weakness. Fluid intake will be measured in the Gatorade group by collection of all bottles by the foodservice staff at the end of each day. Remaining fluid will be measured and recorded by foodservice staff for each subject. Subjects will be instructed not to share beverages or to discard leftover fluid in the bottles. For the standard fluid group, similar collection methods will be performed with distributed water bottles. Foodservice staff will collect all leftover fluids from the meal tray and measure fluid ounces remaining to determine amount consumed. This information will be recorded on the data collection sheet for each patient.Patient ID#:Day 1Day 2Day 3

Weight (lbs)

Laboratory values-Sodium (mmol/L)-Potassium (mmol/L)-Magnesium (mg/dL)-Calcium (mg/dL)

Fluid Intake (oz)

Urine Output (mL)

Laboratory values will be collected at baseline and once daily immediately before the morning meal. Nursing staff will collect and record serum electrolytes including sodium, potassium, magnesium, and calcium; these values will be assessed by the average change from baseline to day three, with improvement defined as values approaching the normal range. Daily weight will be recorded each morning prior to breakfast by the nursing staff; in those admitted with dehydration, small amounts of weight gain (1-2 lbs) are predicted to occur to account for fluid replenishment. Weights will be recorded on the data sheet by nursing staff. Urine output and concentration will be measured by daily urine collection. Increased output and decreased concentration will represent improvement in hydration status.Results for each of the subjects will be compiled into a data analysis program to determine if an association exists between the type of fluid consumed and outcomes of laboratory markers, weight change, and urine output. Average values will be compared by group in line graphs (such as Figure 1). Statisical significance will be concluded when P < 0.05.Figure 1. Average Serum Sodium (in mmol/L) Dissemination PlanFollowing the conclusion of this study, results will be presented to Biloxi VHAs physicians, rehabilitation dietitian, clinical nutrition manager, and clinical manager of the rehabilitation ward. Improvement in hydration status (or lack thereof) will be presented to the interdisciplinary team to determine the next step in improving or changing protocol. Average changes in laboratory results after three days will be portrayed (as in Figure 1) to show the differences between the two experiment groups. Average change in urine output and daily weights will be similarly illustrated to show the average changes between groups. The extra cost of providing Gatorade to the patients may also be calculated and presented to the interdisciplinary team and budget managers to reinforce the need for change. If the predicted hypothesis holds true that Gatorade does not improve hydration status better than equivalent fluid replacement of water and the regular diet order, the hospital will likely save money by changing the protocol to an optional treatment. Further research might also be suggested for the VHA with a similar study design on diabetic and/or hypertensive detoxification patients and Gatorade consumption. Future hospital protocol should consider comorbidities of the patients prior to providing Gatorade to detoxification patients. Patients with diabetes may be provided a sugar-free or reduced-sugar electrolyte beverage upon request to promote electrolyte balance. Hypertensive patients should be provided an electrolyte-enhanced beverage only if sodium levels are initially low and sodium replacement is considered necessary. Other patients without pertinent comorbidities should be provided adequate fluid to meet individually estimated needs. A diet order with standard beverages (coffee, juice, tea, milk, kool-aid, water) should be provided along with extra water to promote rehydration. Gatorade should be kept on hand and offered at patient request. Following the completion of the study, these changes in protocol should be recommended if the outcomes of the study conclude no significant benefit from Gatorade consumption. The proposed changes in protocol would not only enhance patient stay by individualizing needs and care but also improve the use of funding and resources at the Biloxi VHA.ReferencesMaldonado, J. R. (2010). An approach to the patient with substance use and abuse. Med Clin North Am, 94(6), 1169-1205, x-i. doi: 10.1016/j.mcna.2010.08.010McKeon, A., Frye, M. A., & Delanty, N. (2008). The alcohol withdrawal syndrome. J Neurol Neurosurg Psychiatry, 79(8), 854-862. doi: 10.1136/jnnp.2007.128322Miller, K. C., Mack, G., & Knight, K. L. (2009). Electrolyte and Plasma Changes After Ingestion of Pickle Juice, Water, and a Common Carbohydrate-Electrolyte Solution. Journal of Athletic Training, 44(5), 454-461. Rundio, A., Jr. (2013a). Implementing an evidence-based detoxification protocol for alcoholism in a residential addictions treatment facility. Nurs Clin North Am, 48(3), 391-400, v. doi: 10.1016/j.cnur.2013.04.001Rundio, A., Jr. (2013b). Understanding alcoholism. Nurs Clin North Am, 48(3), 385-390, v. doi: 10.1016/j.cnur.2013.05.001Substance Abuse and Mental Health Services Administration (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. 14-4863.