Hydration V Dehydration.

[QRQ 30]

This is just a question I am throwing up for discussion. Today the trend seems to have swung to the extreme of hydration. You see people carrying and suckiong on bottles of liquid all of the time. A local TV station is handing out bottles to children with marks to show how much they must drink every 30 minutes. At the same time it is a real porker who is handing out the bottles. With all of the talk of an overweight and obese population I wonder how much is just due to excess fluid. I always thought of this as a wive's tale but my parents used to tell me that if I didn't slow down on the iced water, my belly would stretch. There may be something to this after all. Many of the "beer bellys" we see in the AO have nothing to do with being fat -- just distension.

How many hypertensive people in the country are super-hydrating at the same time they are on diuretics?

I guess my point is that the correct action may be somewhere in the middle. What do you boxies think? It might make an interesting study but I doubt if the bottled water and sports drink industry would fund you.

[Solid]

I was under the impression that water was like vitamins- if the body needed/wanted it, it would use it, and if not it'd be urinated?

Solid

[The Reaper]

Originally posted by Solid
I was under the impression that water was like vitamins- if the body needed/wanted it, it would use it, and if not it'd be urinated?

Solid

Do a search for "hyponatremia" and get back to us with what you discover.

TR

[Solid]

Hyponatremia means ‘low concentration of sodium in the blood’. Sodium is an important electrolyte (an element with an electrical charge - in this case Sodium is positive and represented as Na+) which plays a role in water balance and muscle contraction. Sodium is required to draw water through permeable membranes in the body and thereby distribute fluid throughout the body. When you sweat, you lose water and salt, and salt is made up of sodium and chloride and is represented as NaCl, so lots of sweating means you are depleting your sodium stores in the body. If your sodium levels in the blood get too low (hyponatremia) you will no longer be able to move water across permeable membranes and you will become dehydrated - even if you are drinking enough water. You can drink all the water you want, but if you don’t have the sodium present to move it from the gut to the bloodstream, you don’t stand a chance.

Sorry, I was going on what my GP told me when I asked. I guess he didn't think I was threatened by this... :eek:

Solid

[The Reaper]

Originally posted by Solid
Sorry, I was going on what my GP told me when I asked. I guess he didn't think I was threatened by this... :eek:

Solid

You neglected to mention that it is common among people doing large quantites of water over extended periods, like while rucking.

You also failed to mention that it can kill you.

I have seen it happen many times, and we issue ORS to our students and soldiers.

In the old days, it was why we took salt tablets.

TR

[Roguish Lawyer]

TR:

What do you think of Gatorade and other drinks that claim to replace electrolytes?

[The Reaper]

Originally posted by Roguish Lawyer
TR:

What do you think of Gatorade and other drinks that claim to replace electrolytes?

Better than just water, plus, IMHO, the flavor causes you to drink more of it.

TR

[Guy]

Originally posted by The Reaper
You neglected to mention that it is common among people doing large quantites of water over extended periods, like while rucking.

You also failed to mention that it can kill you.

I have seen it happen many times, and we issue ORS to our students and soldiers.

In the old days, it was why we took salt tablets.

TR

I'm a victim of "electrolyte imbalance"...then I went down one time for "over carbohydrates" with out hydrating properly.

[P36]

I was hospitalized for hyponatremia while in 2001 out in Huachuca. It was NOT a good time had by all. Everyone preaches water water water....little did I know it could have killed me.

[NousDefionsDoc]

Mmmm

IMO, water is the elixer of life. Like any good thing, you can over do it and I don't believe in forced drinking by the numbers. You should however stay hydrated. I would venture to say that dehydration is much more common than hyponatremia, although Bragg and Benning probably have more than their fair share of the latter.

I drink water, in small amounts, all day long. Not uncommon for me to drink 3-4 32oz Nalgene bottles if its nice out. During what I would call moderate activity.

I like the idea of the Camelbacks. You are forced to take fairly small drinks and work a little to get it. I would be interested to hear of any cases of hyponatremia through their use.

Of course operationally, water comes 3rd behind ammo and comms gear. But a close third. Don't do much good to be well hydrated with a hole in your chest because you ran out of ammo and couldn't get CAS.

[P36]

Well, there I was...knee deep in cactus, 110 degrees out and we were out for a pleasant jaunt. I had a 100oz Camelbak and since I've been a heat casualty before , I knew to take frequent sips off the thing. About 2 hours into the hike, I start getting that dizzy headache feeling and assuming I need more water, drink more. I continue to feel worse and to drink, I still don't have to pee after draining the bag. Hmmm. Boy, I must really be dehydrated. We're near a Ranger station, one of whom gives me some rehydration salts to add to the Camelbak and since I've not had to use the bathroom and my head is splitting, I fill it up again. Anyway, after about another hour, I finally convince someone to get me to the clinic on Huachuca, about a 1 1/2 hour ride away...they run a blood test, look rather concerned and call an ambulance to take me to the ER downtown in Sierra Vista. In the meantime, they start an IV and put some solution in it that IMMEDIATELY causes me to projectile vomit...hahahaha, I feel sorry for those near me :-). I'm put on a gurney and taken to the ER, it's now nighttime. They start me on something that makes me pee every 10 $%@%#$ minutes, along with an IV full of crap like postassium. I finally got discharged at midnight after being forced to drink a cup of liquid postassium and given instructions to eat bananas and salty foods for the next couple of days.

That's my story. I'd never heard that you could almost kill yourself by drinking too much, and after looking it up, learned that a girl in basic training actually died after drinking too much water in too short of a time, trying to prep for a urinalysis.

BTW, this was a "Staff Ride" during ANCOC and one of the FAT piece of shit instructor's actually fucking accused me of trying to sham a ride off the hill we were on. She was rather distant after discovering I came pretty close to not being around anymore. She didn't think I should go at all, then asked if she should perhaps escort me. People always accuse others of what they themselves are guilty of. Fat Piece of Crap. Oh and while I was damn near dying in the van, on the way to Huachuca, the cadre stopped for a rest stop to get ice cream for themselves-relaxing around, until one of the students, pointed out that I looked like I was going downhill. ANCOC, ah, A NCOC, my mentors.


So why is it called a staff ride if you end up walking up and down hills in the desert, studying the history of the US Calvary and the Apache Indians????? Anybody?

[Sacamuelas]

P36...
a few questions:

Were you hydrating prior to the your pleasant desert jaunt the night before or even days prior to get "prepared"?
Were you intaking electrolytes the prior days or had you been exercising heavily and replenishing only with water for the days leading up to your episode?
Sipping on a camelbak over a two hours period- Did you finish the whole thing?

[ccrn]

Originally posted by NousDefionsDoc
I would venture to say that dehydration is much more common than hyponatremia, although Bragg and Benning probably have more than their fair share of the latter


Agreed.

In my flield we consider the general population to be dehydrated overall. People wince when I suggest to them they need to drink 6-8 large glasses of water a day. They prefer to spend money on mountian dew, jolt cola, and 44oz big gulps full of soda.

Dehydration can cause lethargy, difficulty concentrating, confusion, even coma and death. For the average individual not in crisis this is manifested by decreased performance across the board. Students should take note.

Profound hyponatremia can be fatal as previously stated. S/sx are caused by swelling of neurons as a result of decreased osmolality of extracelular fluid causing a fluid shift into the cell.

This can be manifested by CNS S/sx ie malaise, anorexia, nausea, vomiting, HA, confusion, lethargy, seizures, and coma. Much the same as dehydration.

For the provider in the field it is imprortant to take assessment, recent Hx to determine which way to go and then tx according to protocols and training-

ccrn

[The Reaper]

Not a Doc, but I did stay at a Holiday Inn Express recently, and I have some practical experience at this, so here goes.

Here is my .02.

Keep drinking while moving, especially if you have ORS or other electrolyte replacements.

Keep drinking regardless, even if all you have is water, but salt your food heavily, or if you have plenty of fresh water, consider using your MRE salt packet in one of your quarts. Tastes bad, but works. I would save my salt packets or borrow some.

Drink heavily at water points. Free weight, since you don't have to hump it. See if they have any ORS.

Keep eating. If you do not have pogey bait, save your snack type food from your MREs and munch every few hours while on the move. Food will help some with the elyctrolyte issue, and gives you quick carbs to burn before you are depleted completely.

Urine color and frequency is another very good indicator.

When permitted, move with a buddy and monitor one another.

Recognize the difference between tiredness and pain from exertion, and symptoms of medical issues. Treat at the earliest opportunity. If you are really messed up, see the Doc before you go Tango Uniform. Out on a 12 mile individual movement, there may be no one to hear you scream. This stuff is insidious, and will affect your judgement early on.

Try to prevent it, recognize the symptoms, apply basic treatment, and see the Docs if you do not respond quickly. That is all.

Good luck.

TR

[P36]

Originally posted by Sacamuelas
P36...
a few questions:

Were you hydrating prior to the your pleasant desert jaunt the night before or even days prior to get "prepared"?
Were you intaking electrolytes the prior days or had you been exercising heavily and replenishing only with water for the days leading up to your episode?
Sipping on a camelbak over a two hours period- Did you finish the whole thing?

-I don't recall doing anything special to prep. Quite honestly, this was not some sort of forced march, but an actual walk through the desert, visiting historical sites where battles were fought between the calvary and Apaches.

-Just water (and I think that was a KEY ERROR-in retrospect, after gaining some knowledge), no special exercise, just the PT we did for ANCOC and gym workouts.

-After I started to get the dizzy headache, I thought it might be indicative of dehydration and began to drink more. So within 3 hours, I had finished it and started on a new one. (BTW-I too love the Camelbak, but if you don't know there's a limit to how much water you should ingest in a period of time and know how much your Camelback holds, well let's say, it's easy to drink more than is healthy-without realizing it-I corresponded with an Army medical researcher on this topic after the fact, since I'd never heard of HypoN, he had seen some problems with soldiers downing too much with the Camelbak. It's not the device's problem, it's our ignorance of the injury).

The odd thing about this, was that I did not pee more than once throughout the day AND the sypmptoms felt the same as being dehydrated. Dizzy, headache, nausea and weak.

Here are the results of my blood work for those to whom it might mean something:
Sodium: 132 (low)
Potassium 3.1 (low)
Chloride 102
Carbon Dioxide 26
Glucose 116 (high)
BUN 6
Creatinine 0.7
Calcium 8.2 (low)

[Eagle5US]

I have seen multiple cases of hyponatremia as well as "water intoxication" - the condition preceding true hyponatremia. It is interesting to ibserve to say the least.

The gatorade question brings up an interesting point as well...salt sontent in full strength gatorade is high enough to actually PULL water from your surrounding tissues in order to process the drink through your gut. You trade short term loss of fluids for processing of the electrolyte compounds in the "sports drink" This is a fine and accepted practice for actvity of short duration. Over long periods however (> 4 hours) this creates and imbalance of it's own...it has required more fluid to process than has been able to be replaced.
Current sports medicine recommendations include alternating bottles of HoH and sports drinks if more than 4 bottle of ANY fluid are anticipated to be consumed.
The alternative is to cut the sports drink by 1/3 to 1/2 with HoH producing a mixture that is less concentrated, thereby allowing your pbody to absorb some of the HoH while still processing small amounts of electrolyte.

Agree 100% with TR's observations, Doc Keaton would be proud Sir!

Eagle

[NousDefionsDoc]

QRQ,
Been reading Gabe Suarez?:munchin

[P36]

"It is interesting to observe to say the least."

Well, it's even more interesting to go through it! Especially after they put Lasix in the IV. It's rather humiliating to have someone measure the amount you pee. "Let's see, that was 800cc, good job, only a couple thousand more to go!" Meanwhile, the whole time, I'm zoned out on some anti-nausea drug and just desperately want to be left alone to die........

Here is an excellent link to a case study of a soldier: http://www.physsportsmed.com/issues/2000/09_00/flinn.htm





Here is a description from a website:

Overhydration is disruptive to nerve cell function and can produce symptoms of lightheadedness or mild vertigo. Severe overhydration is known as water intoxication. It produces neurological symptoms ranging from disoriented behavior to convulsions, coma, and death. This increase in intracellular water concentration can also result in a decrease in hydrostatic pressure. As the pressure drops, water moves out of the plasma, causing a loss of blood volume in the body and this can lead to circulatory shock.

Overhydration and water intoxication can be avoided with careful monitoring of fluid intake when sweating heavily or when ill with diarrhea or vomiting. Under these conditions, drinking plain water will not restore sodium loss nor will it adequately rehydrate the body. Simply adding a little bit of salt to water, to fruit juice, or vegetable juice can help the body to restore the lost sodium. Sport drinks contain sodium to help athletes to quickly restore sodium loss. Additionally, when vomiting and diarrhea are present, sport drinks can help to restore sodium and other electrolytes that are quickly lost during these types of illnesses.

[NousDefionsDoc]

It's rather humiliating to have someone measure the amount you pee. "Let's see, that was 800cc, good job, only a couple thousand more to go!"

Better red (in the face) than dead. P' if that's the most humiliating thing a medic ever does to you, you ain't hangin' with the right medics....:D

Agree 100% with TR's observations, Doc Keaton would be proud Sir!

HEY! I trained him first!

[Doc T]

Originally posted by P36
-\
\ Dizzy, headache, nausea and weak.

Here are the results of my blood work for those to whom it might mean something:
Sodium: 132 (low)
Potassium 3.1 (low)
Chloride 102
Carbon Dioxide 26
Glucose 116 (high)
BUN 6
Creatinine 0.7
Calcium 8.2 (low)


none of your labs are all that abnormal...I am actually surprised you were symptomatic...but all labs have mildly different ranges for normal. The low end of Na is typically about 135....

doc t

[DoctorDoom]

[x

[P36]

I don't know anything about blood levels, etc. All I can tell you is that I drank no less than 3 camelbaks full of water that day and pee'd once. When the clinic did the bloodwork, they seemed all worried, called an ambulance and sent me to the ER. When I got to the ER, they gave me another IV with Lasix (sp), which started me urinating every few minutes for 3 hours. Then they made me drink a thing of potassium prior to releasing me, with orders to continue more potassium.

I've never felt worse in my life.

[DoctorDoom]

x

[ccrn]

I didnt think the labs were significant either. The Na wasnt critical, the glucose was wnl as was the Ca, but the K was a little low. Were I work we replace potassium as it can cause dysrhythmia.

Perhaps he might need a supplement or better yet eat foods rich in K once in awhile-

ccrn

[NousDefionsDoc]

ccrn,
The patient in question, P36, is a female.:D

[The Reaper]

Originally posted by NousDefionsDoc
ccrn,
The patient in question, P36, is a female.:D

Doooohh!

Been waiting for that shoe to drop.

Just shows why it is hard to practice medicine on the internet.

TR

[ccrn]

Originally posted by P36
...the cadre stopped for a rest stop to get ice cream ...


I failed to pick up on that during my H&P sir-

ccrn

[The Reaper]

Originally posted by ccrn
I failed to pick up on that during my H&P sir-

ccrn

That would be Ma'am, in case you missed the previous.

TR

[Sacamuelas]

TR, I think ccrn was talking to NDD... or was that a shot at NDD from his boss! LOL

Originally posted by P36
I don't know anything about blood levels, etc. All I can tell you is that I drank no less than 3 camelbaks full of water that day and pee'd once.

Aahhhh.... that makes more sense to me P36. YOur original post made it sound to me like you had drank 100oz over several hours of exercise in a desert- which would not be overhydration. I missed that part about refilling at the Ranger station-just thought you put salts in it. Even then, it is surprising to find the symptoms you were having.

THat is why I wondered about your pre-exercise regimen. NOw, I am more clear on what happened. I knew there had to be more to the story than what I interpreted from your first post.

CCRN-
WTH? ;) She went on a "jaunt" instead of describing it some other way, she said pee instead of piss... OBVIOUSLY she is a female and not a crude male. LOL situational awareness..HAHA

[ccrn]

Originally posted by Sacamuelas
TR, I think ccrn was talking to NDD


Correct sir.


she said pee instead of piss... OBVIOUSLY she is a female and not a crude male. LOL situational awareness..HAHA


One can never be too sure these days sir.


ccrn

[P36]

Who needs the Comedy Channel, anyway? :D Sorry if I wasn't clear in my original post. Yes, I drank a ton of water that day. It was a "learning" experience. Seriously, it was.

Who knew you could kill yourself by drinking too much water? Common sense would say that you would just empty it out the other end, right. So if you didn't have to go, you must be REALLY dehydrated! Live and learn.

[NousDefionsDoc]

"No-P36" LOL

[VMI_Marine]

Originally posted by ccrn
In my flield we consider the general population to be dehydrated overall. People wince when I suggest to them they need to drink 6-8 large glasses of water a day. They prefer to spend money on mountian dew, jolt cola, and 44oz big gulps full of soda.

Dehydration can cause lethargy, difficulty concentrating, confusion, even coma and death. For the average individual not in crisis this is manifested by decreased performance across the board. Students should take note.

The one semester in college where I felt truly awake and alert during every class, I was taking a PT-intensive OCS prep course and bringing a 32 oz bottle of fluid with me to every class. After that, I stopped going for the coffee and soda on road trips.

The gist that I am getting from this thread with regards to overhydration is that under normal circumstances it is not a threat to Joe Citizen. Those of us in the "business", who spend a lot of time outside of normal circumstances, need to monitor our hydration and food intake because the stress we place on our bodies interferes with the kidneys' ability to process and excrete the excess fluid. Is the lieutenant on track here, or am I wandering with the map upside-down again?

[18C/GS 0602]

Originally posted by VMI_Marine
Those of us in the "business", who spend a lot of time outside of normal circumstances, need to monitor our hydration and food intake because the stress we place on our bodies interferes with the kidneys' ability to process and excrete the excess fluid. Is the lieutenant on track here, or am I wandering with the map upside-down again?

While there are reports of extreme exercise causing decreased renal function in the medical literature I think that the majority of cases of exercise induced hyponatremia are due to environmental factors i.e. someone losing a large amount of sodium in their sweat but only replacing it with water/sports drinks and no oral rehydration salts (ORS) or food. I think there are two reasons for this. First many extreme athletes are very aware of dehydration, and how it can cause a decrease in performance, but not aware about how over hydration can also cause problems. The second part is that sports drinks are not enough by themselves- when a large amount of sodium is lost you need ORS or food, which have much higher content of sodium than sports drinks. It boils down to someone losing more sodium than they are replacing, rather than exercise causing the kidney not to function properly.

[ccrn]

QUOTE]Originally posted by VMI_Marine
Is the lieutenant on track here, or am I wandering with the map upside-down again? [/QUOTE]


Sir, its more like this:

Rather than renal function this is more a matter of osmosis ie the shifting of water in the body, between inside and outside the cell.

There is a saying in medicine that where salt is water will follow. Outside the cell is where sodium likes to live, inside the cell is where potassium lives. When sodium is low outside the cell water tends to shift from the outside to the inside ie overhydration and hyponatremia(attracted to the potassium). This also causes cells to expand causing the neuro symptoms of hyponatremia. When sodium is high outside the cell ie dehydration this causes water to shift to the outside (attracted to the sodium) of the cell shrinking it. When one salt is concentrated more than the other the water will go to it.

If the cell can be thought of as a "battery"of sorts (depolarization)this can explain why we dont function well ie not contracting optimaly or conducting correctly when poorly hydrated. If a neuron doesnt have enough water in it, or too much it wont "conduct" correctly and therefore difficulty concentrating, confusion, lethargy etc.

My battery analogy isnt a very good one but I think it effective when considering hydration. If the battery is too full it can expand causing damage while to low it cant conduct.

To summarize if the cell is swollen with water (overhydration;hyponatremia) it cant funtion properly. If the cell doesnt have enough water in it (dehydration) it also cant function properly.

Respectfully-

ccrn

[Sacamuelas]

As much as a 5 to 10 lb weight loss has been recorded in athletes in a period of 1 hour during endurance athletic events under hot and humid conditions. Essentially all of this weight loss results from the loss of sweat. Loss of enough sweat to decrease body weight only 3 % can significantly diminish a person’s performance, and a 5 to 10 % rapid decrease in weight can often be very serious, leading to muscle cramps, nausea, and other effects. Therefore, it is essential to replace fluid as it is lost.

You need to provide replacement of Salt AND Potassium. Sweat contains a large amount of salt, for which reason it has long been stated that all athletes should take salt tablets when performing exercise on hot humid days. Unfortunately, overuse of salt tablets has often done as much harm as good. Furthermore, if an athlete becomes acclimatized to the heat by progressive increase in athletic exposure over a period of 1 to 2 weeks rather than performing maximal athletic feats on the first day, the sweat glands also become acclimatized, so that the amount of salt lost in sweat is only a small fraction of that prior to acclimatization. This sweat gland acclimatization results mainly from increased aldosterone secretion by the adrenal cortex. The aldosterone in turn has direct effects on the sweat glands, increasing the reabsorbtion of NaCl (salt) from the sweat before it issues forth from the sweat gland tubules onto the surface of the skin. Once the athlete is acclimatized, only rarely do salt supplements need to be considered during athletic events.

On the other hand, recent experience by military units exposed to heavy exercise in the desert has demonstrated still another electrolyte problem- the problem of potassium loss. Potassium loss results partly from the increased secretion of aldosterone during heat acclimatization, which increases the loss of potassium in the urine as well as in the sweat. As a consequence of these findings, some of the newer supplemental fluids for athletes and soldiers are beginning to contain properly proportioned amounts of potassium and NaCl.

Note about patients experiencing hypokalemia. When the normal K+ concentration falls below approximately 1/2 to 1/3 the normal value (4.5 mEq/L) , muscle paralysis or at least severe muscle weakness often develops. This is caused by effects on the nerve and muscle fibers membranes that prevent transmission of the normal action potentials.

[cbtengr]

I have found myself doing a lot of physical work in very hot and humid conditions. I sweat profusely and at night I experience some pretty severe cramping in my legs. I make it a point to stay hydrated in order to avoid the cramping but am still having some issues. How important are the intake of electrolytes in order to control the cramping?

Rather than spend large amounts of money on sports drinks such as Gatorade I make my own, the wife found the recipe online and it consists of the following:
1/4 Cup lite corn syrup
1/2 teaspoon of Lite Salt Iodized Salt and Potassium Chloride
Sugar free flavoring
2 qts of H20

Is this recipe adequate? Do any of you have your own concoctions that you would recommend?

[CSB]

When we were in Somalia (101st Airborne, 1984) our medics would insist that from time to time we piss on/on a device that looked like a flute. Then they would look through an eyepiece and declare what the specific gravity was. Then they would say "Your'e OK, or drink more" and so on.

I had never seen this before, and havent seen it since. Portable urine specific gravity testing as a way to avoid dehydration.

Is this a valid procedure?

====

Oh, by the way, the best training drink ever: I invented this myself when training at Ft. Bragg in the late 1970's:

Gatorade and cheap white wine, half and half, ice cold.

Yummers, extremely refreshing, and I never suffered from dehydration even when rucking/running in a North Carolina summer.