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Running head: ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES1

Alcohol Detoxification and Hydration Outcomes


Molly Chaffin
The University of Southern Mississippi

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

Introduction
Consumption 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

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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, electrolytesupplemented 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-

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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 electrolyteenhanced 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

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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 electrolyteenhanced 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

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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.

ALCOHOL DETOXIFICATION AND HYDRATION OUTCOMES

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.

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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

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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 1

Day 2

Day 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

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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)
150
149
148
147
146
145
144
143
142
141
Day 1

Dissemination Plan

Gatorade
Fluid

Day 2

Day 3

Day 4

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Following 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.

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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 reducedsugar 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.References
Maldonado, 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.2010.08.010

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McKeon, A., Frye, M. A., & Delanty, N. (2008). The alcohol withdrawal
syndrome. J Neurol Neurosurg Psychiatry, 79(8), 854-862. doi:
10.1136/jnnp.2007.128322
Miller, K. C., Mack, G., & Knight, K. L. (2009). Electrolyte and Plasma Changes
After Ingestion of Pickle Juice, Water, and a Common CarbohydrateElectrolyte Solution. Journal of Athletic Training, 44(5), 454-461.
Rundio, A., Jr. (2013a). Implementing an evidence-based detoxification
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Substance Abuse and Mental Health Services Administration (2014). Results
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National Survey on Drug Use and Health: Summary of National
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