0 Hyponatremia? - Heat Exhaustion? 0 "ATC rankings of - - PDF document

SLIDE 1

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"P'S'T PATS

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Research Fund

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Sponsors Flyers

I N S'TIT"(n,'t " Ho.1 "'"0"".1..,.." A..Id."oo."d T.o.lmo"'

Introduction

0 Problems we are faced with-Why has the

incidence

• f hyponatremia

increased?

• The EHS (Tc)and dehydration dilemma
• Experimental versus FieldStudies

0 Majorfluid regulating hormones

• The body's response to lowblood pressure

0 Threeformsof hyponatremia 0 Electrolytestudiesin FB and Ice Hockey

• Na+supplemented versus un-supplemented

r

I Problem- Which are Heat Illnesses?

0 Heat Cramps

(EAMC)?

Heat Exhaustion?

• Symptomatic

dehydration

0 Hyponatremia? -

This can be prevented!!

0 Exertional Heat Stroke (EHS) - YES 0 A heat illness is defined as a condition in

which the primary treatment is rapid cooling!!

[ N"S'T'T'1'OT "

Hoal"'"o" ,..1..,.." A..Id.",o ""d T.oalmo"'

"

• od T.o.'mo"'

Sodium Depletion Illness (Hypovolemic Hyponatremia)

Sandra Fowkes GodekPhD, ATC Professor/Director,The HEATInstitute West Chester Universily of Pennsylvania

I N"S"TI,""" T "

Ho.' 'b" ,..1..11." A..Id.",o ."d T.o.lmo"'

Introduction

0 Critical questions to which we don't have

all of the answers

0 By the numbers - sweat sodium losses 0 Hyponatremia versus heat exhaustion 0 Hypovolemic hyponatremia

• Signs/symptoms
• Management and prevention

[F:]" , ,""

lIIIiAtU

I NS"r",..:'t'tJ '1' " Hoal "'"." E..I..,.""".Id."," ."d T..almo"'

Problem - What causes Exertional Heat stroke?? HS ATC Survey

DombekC"., v...g"".1 JATSoppl2006 0 "ATC rankings of 14itemsthat predispose

athletes to EHS revealed they consider.."

• 1. Dehydration

(2.6 rank)

• 2. High Humidity (3.4 rank)
• 3. High ambient

temperature (4.3 rank)

• 4. Acclimatization

(5.1 rank)

• 5. Physical

fitness (5.7 rank)

• 6. History of heat illness

(6.1 rank)

• 7. Exercise

intensity /6.2 rank)

1

SLIDE 2

1

..

I

E

.eat .,." A.oid..,. T"""""

Problem -What causes Exertional

Heat stroke??

Dombek,C"',Y",gl"I,'JAT',ppl2006

. Dehydration was ranked significantly higher

than all other factors except high humidityll

. However-The overwhelming expert

consensus is that metabolic rate (exercise intensity) is the sinclle most important factor related to elevated core temperature

• Dehydration

at best has minimal affect

I . So why do ATC's still think this way??

~,

.. . ., 'f~ .

Where does your information come from?

II!!,~,t

,--,

.eat ".." ""'.'0' A."d.".

• ,d T,""'...

I Is there a Significant correlation

between Tc and level of Hydration?

" .,.,

.0'

;;\\{~

" ""h"",II.,

r= 0.198, p=0.294

"

J

I

I N'f§TI 4"'{JT E

Run ner~'o~'~;~~~A':O'~:T;:;~on

. When runners get hot, they slow down

. Some

reach Tcmaxearly

. Some at the end

'. Tcis not related to %

I

dehydration

. Tcmax of 104 -106 DF

are common and well

r; toleratedlll

(;-13-" "" j

• 1S"""'~'"

'" T ,,-,,<g

ii."" ~" I""~'F . "., ",/ ..; .... " ""lIf<

::-.rX'"

~ ",1

~--!, , .

~"",~ .~v

~:::..."'-.,,~-

;;:'j 101.8 Of '" ""-';:;":':,:~;r',:""".,';': '"

I

Byrne, Lee, Chew el al MSSE 06

, ,FST-~,,>t~'UCT E .eat ._" E."""'" A.oido". T""","

Is there a Significant correlation between Tcand level of Hydration?

.. u

'" l"

~

.

':~'..': ,"',. . "

" r=,76

p< .DDDt

".

." D...", ,

Bartolo;,/ AR. Fow'" God.. S, Sw..1 "I. "d 00" '.m"."I", "'PPO'" to D,hy,"'U.,lnd"," "",,'monl,lIy "",u. during ,,'u,1 p"

• n p",U"

I'

ColI'g' ,..'hall pia,.." ,J A!h/ T,,/n '39(2), 2004,

, N;S~1'" .1""""I' .: ,... On... A...d.n.. .nd I.......... Field Sludy during FBPraclice

Experimenlal, fixed workload 42

"

40 u 39 I

i 3HI

8"

.~

'" '... '." "" '. ~.',

. ,

,i~

J;Wc:L

., ., ",...'O.h",,"'.n

r = .76, P < ,0001 I ,iFS"'T..,'.:'F"tJ'1' E

,..I III,... ".,..11.,A...d.n....d T ,

"

U n.

,

,

En.

. , '" .,

"",",~."..,.."

r = 0,198, P = 0,294

Runners during a Marathon :~~

:' -2-'--4+"

• -0

';;'" 107m;n

~

.

"

.

:o

. ~9'F

[ ,." ...~;- r 1C .~'" ,-~OSmi"

~::" .

. ::::-? 106'

,,::.'

~

3"!

. ,

101'F

;'."",i~9 T;"~~",I";" '"

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8-7-.-0-,,-1;-12

::.,

~

~,- 41.0

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40.'

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/

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.) 3O"""::~["";':-lm;";;' ,;" Byrne, Lee, Chew el al MSSE 06

2

SLIDE 3

1

I

• I

g

I

I

I

I

I

I ConcluSiOnSs yrne Lee Chew et al msse 06 I

. .

I.17 of the 18 runners had a Tcmax ;:: 103 of

:

• In

my lab the experiment for them was ended

• I. 10 of the 18 runners had a Tcmax > 104 of

I - In any lab in this country the trial is done

. % dehydrationrangedfrom 0.9%- 3.9%

. "Core temperature responses demonstrated

nosignificantrelationshipto absolutel:!.mass

~

",' .o

,

r % dehydration"

(lWCl ;

H..'ill,...".".1100 "ald.,.. .,dT,..tm.,.

I

I

I

I:

II

I

I

,

""

,os ,..

Athletes get hot

• so what's

the

big deal??

'03 ~'02

i

~ 101

'03 98

• LM
• BKS

F~'" Gad..5," al.JAT 2'"

IiIltl;

97

".1 11m. II~ ,"'. 11m. 11m. "'" 11m. ,~

, 2 3 , 5 . 7 8

,....---

, N"S'T I 4'~lJT g H.aI "_.. , A.ald.,.. .ad T,.almaof

The EHS and Dehydration

Dilemma

. It clouds the fluid/electrolyte

balance issue

and provides a false sense of security ! . It promotesthethinkingthat drinkingto

"

replace all fluid losses will prevent EHS

. We don't

know what causes EHS but it is

NOT dehydration

. 2 - 3% body mass loss during

exercise is

normal, expected and well tolerated

~1\Ct

I rFS'T' ,"rU4' ., H..' ,",... ".'...11., A.ald.,.. .ad T,aaim.,'

Triathletes during a Race

. Mean Tc max= 38.1°C

(100.6°F)

. Mean % dehy = 3%

. Change in mass was not

related to finishing Tc

. "Body mass loss of 3% was

found to be tolerated by well trained tri-athletes ...m without any evidence of ~;~;~OregUlatOry failure"

• Laurson

et al BJSM 06

I

I N""'Pl'c,T'tJ't "

H..' ;II,... ...1...11., A.ald.,.. .,d T'..'m."

Tc and % Dehy in Pro Players

107 45 different players in 183 player practices

,os

I '00

g

Players were symptomatic

• n only 4 occasions

""

~Vvtl;

"'~ ~ . ~ . .

P.~,' Doh"""M ." . ~"""

I ""S'1' 1,"'1"'71' E Haai .,... ..aI , A.ald.,.. .,d h""'"

I MajorHormones Involved in the : control of Blood Volume (BP)

. Released

when blood volume and blood pressure are low

• Vasopressin (ADH)
• Renin-Angiotensin
• Aldosterone

. Released

when blood volume and blood pressure are high

• Naturetic Peptides

. ANP

. BNP

. Urodilantin

fii \VC i 3

ra ,065

)

P a 0,39

Q(

. ';"":

. =

:"i4....

. ., : : :,:::

"

.. ; ':-':.

:., '.

SLIDE 4

( ""'5'1"">4' "1'1' r,

Heal ;II"e.. "01"0110" A,oldo"oo

• "d (,oatme"'

The Body's Response to Low BP (Salt/blood volume Depletion)

. Kidneys release Renin . Renin combines withAngiotensinogen to

form Angiotensin I

• I. Angiotensin Iis converted to Angiotensin II

, by ACE

0 Angiotensin

IIstimulatesseveral

I

mechanisms that raise blood pressure

Aldosterone promotes Na+ Uptake in Kidneys

( N';,F1'l,'1"'t)T E Heal"'"0" "0'"0110" "o'do"oo

• "d T,eo'me"'

What is Normal Body Mass?

290 mOsmlkg. AVP Aldosterone Thi"t 280 mOsm/kg

.

Naturetic pepMes No thirst

Blood Electrolytes?

Blood Glucose?

Body Temperature?

~

IN'ST,"rUTE Heollll"e.. "0'"0110" A,o'do"oo o"d "'o'me"'

Angiotensin II

• Causes

Vasoconstriction of BloodVessels

• Stimulates Brain to release Vasopressin

(ADH)

0 Increases H2O reabsorption 0 Stimulates Thirst

• Stimulates

adrenal cortex to release Aldosterone

0 Increases Na+reabsorption

ri~,

Body Fluids

• t Blood

Volume

• t

BP

E H.ollII"... "0'"0110"A,o'do"oo o"d T..olme"' 290 mOsm/kg 280 mOsmlkg

HYPOhYdrati;;;;-

./ Hyperhydralion

• -v-

Euhydration

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I ,.S"I'"",XI"(j", E Heoll""e.. "0'"0110" A,aldo"oo o"d T,ealme"'

~~"")."Yd"'tiM'=""'"

~

290 mOsmlkg 280 mOsmlkg Hypohydration \.

) Hyperhydration

y

Euhydration

4

SLIDE 5

~

[ ",,"'S TT4' [11' g

What is co~:;;;~;;';"~~~~;;'~~~'dratiOn?

90 mOsm/kg 280 mOsm/kg

. .

AVP Naturetic pep[;des

f

~~~~~terone Nothirs' A 2,2 % I ss of mass 48,3 kg 'w 151,7kg

. With Sosm (285 mOsm/kg) body mass normally

fluctuates between: I

' 79,2 kg and 80,8 kg in a 80 kg (176 Ib) male (5 Ibs) , 64.4 kg and 65,6 kg in a 65 kg (143 Ib) female (- 3 Ibs) , 29,7 kg and 30,34 kg in a 30 kg (66 Ib) child (1.4 Ibs) , 148,3 kg and 151.7 kg in a 150 kg (330 Ib) FB LM (- 8 Ibs)

r

! E H,o' m",.. "°10011°"A,oldo"," o"d ,,"o'm'"'

Hyponatremia - Na+ Dilution

. Hypervolemic hyponatremia - blood

volume expands and blood Na+is diluted

• This is primarily the marathon/ultra-distance

athlete - water intoxication

• Females may be more prone?
• Probably linked much of the time to ISADH
• Caused

by drinking too much of ANYTHING

(includinq CE drinks)!!

r

I

E H'o' m",.. holoollo" A,oldo"," o"d '"o'm'"'

Changes in Plasma Volume

20 15 J&ti ""'-" ""'-"

~ 10

1

5

!

.. -5

• 10

I

l

"preAM

I .. PostAM

D Pre PM D Post PM

• 15

'owk.. God.k S, B,rtolmi AR,God.k J J, Hydmll,""""' " 00"'9' r"""", ~,y." doll"lloo",.~w. d,y' o,two-'-"y pm""" p"""" AmJ SportsM,d. 2005;33(6)' [ t: H~' m"... ",10011°"A"idoo"

• "d "'oImool

Three forms of Hyponatremia

. ~rvolemic

hyponatremia Normovolemic hyponatremia !::jyQQvolemic hyponatremia

. There is probably a spectrum of etiology

fuI!!!.vol.mi.Hypo""~i' No~ovol'mi. Hypo",'"ml,

HYP'No'.mi. HyPon,'"mi'

.

.

Toomuch sodium loss with inadequate sodium replacement (and ISADH)?? Excessive fluid consumption (and ISADH)??

IF=I '"

II!I WW

Normal serum Na' is 135 -145 mmol/l Clinical diagnosis

• f hyponatremia

is 130 mmol/l Symptoms can begin when serum Na' < 135 mmolll E Hoo'm,... 'voloo'o" A"ldo","

• "d 'reo'm,"'

Hyponatremia - Na+Depletion

. !::jyQQvolemic

hyponatremia

• Low body

sodium leads to a contracted blood volume

• This is the heavy

and/or salty sweaters

• Probably
• ccursmorein males
• Exacerbated

by drinkingtoo muchwater and/orCEdrinks

• Detection
• f the hypovolemia

incollegiateFB

players during two-a-days was the key!

E Hoo'"'"... ",'VO'O" Moldo""

• od'"o'm,"'

Aldosterone Mediated Na+ Re-absorption

225 200

. 175

5 150

~ 125

~

100 75 50 25 Urinary Sodium

Excretion BI

2nd 3rd 4th Days

• f Pre.Season

'SI"II'.""ydlff",""romB',p<,"',

1;

,. " Slo"'ff'."I""",,"Ofrom Om 2 ,.",

,<,05 ". F"""" God,k S,B"""",' AR, God,k J J,Hy'",., "",°," 0011". roo".11 "'Y.. '"""II ,i .'tA/c;u ,,"'oco.., d",>or"""'-d.",",..", pm"'". Am H"". Mod. 2005,33(6' "03-05,

6th Bitt

5

SLIDE 6

to H.,I'" .."..",. M,'d,... ,.d T'."m..'

Fluid and Electrolyte Studies 2003 - 2009

"

H.,. m 01'.. A.,ld ..d T,..Im...

Blood Na+ in Pro FB Players

• ,

'" '" a E ,.

E

BL Day3 Day5

."90iioao', "'e",,",om8L,

Lay9oodLay1" p4) 01 Day 9 Day 11

Fow", GodekS, B,rtoloz<i AR,Kelly M, Ch"B" mB]ood E],,"o]yte, "d P]"m, Volume m NFL F""tb,1l P]'y'" Du"o, P"-",,oo Tmiom. Med Sei Sports Exel 2004;36(5):548

to

H..IIn ..,1...1100 M,'doo.. .od T,..Im...

Blood Na+ in College FB Players (2003 preseason)

145 143

Blood Sodium

• S

141

~ 139

137 135 BL Day 9 Day 11

I.Significantly

different from BL and Day 9, p<OO1,

Day 11 is after 5 practices in 3 days to H..' 1110... ..,'..01'00M,ld,... ..d T,..lme.'

Pre-Season On-site Lab

"

H..IIII '..'...11,.A.,'d ..d Tieolm..1

Blood Na+ maintained at low normal levels at expense of PV

r:'ercent ChaDg~V

8,-n 6

5: 4

,5 2 .. OJ 0 C

~ -2

~-4

,

• 6
• 8

.Significantly

different

from Day3,

p<O.O5,

Day5

to H..III' E..,...I',. A.~d ..d T,.oIm..1

A Problem

. What are the blood K+

concerns specifically in football?

. Hyperkalemia

causes cardiac issues

. These guys are not

the "average" male athlete

6

SLIDE 7

IN'S ...,1;' liT t;

H..I illo... 0,.1,.11.,

A,.Id.". ." h.lm.,1

Blood K+ in Un-supplemented Pro FB Players in 2003

5.5 5.25 5 4.75

1j

4.5

~

4.25

4 3.75 3.5 3.25

# #

~ .\Vv,

BI

Day 3 Day 5 Day 9 Day 11 'SI,rnflo,"",dlU..."'homBI . Si,oiflo.ml,dlU",0IhomD.,3

. N sT. T"T E Hoot .~.. ..., , A,_,oo .,. r_lmom

142 141

Blood Na+ with supplementation

J;vvu'

140

'3 139

E E 136 137

136 135 BL Day3

Supplementation ended t ,.-S'T '.T'U T E H." .,... ...,..11., A,~..". .,. ,,"oIm.'"

2004, 4.5 9 sodium Plasma Volume Increased Perfectly

3.

BL Day' Day. Day'

.Rehy

C'!PJ

rii.\Ct

I N'S 'r"+iflr-.1' t; H..IIII,... 0,.1..11., ".Id.,oo .,. h..lm.,1

Oral Sodium Supplementation

I . Six players

with a history

I

• f heat-related problems

. Orally supplemented

with 4331 mg Na+/day

• '!. saline with meals
• 'I. saline

between practices

. Equal to - 40% of average

players Na+ losses

~,"';;"

• rilltVlA. i

J N.'S"'F"I T""',.

0;

Hoot",." ..., , A",.I.,oo '_on!

.--

I PV in Un-Suppl versus Na+Suppl

. In Na+Suppl PV

expanded 18% by Day 3

15

. PV was never below BL

10

. Clinically different from

5

unsupplemented players in 2003

r;,,\tiJ

20

• 5

BL

Day' Day. Day'

.unsuppl

SNo+Suppl

I rFS'T.I'1'IIT E H..' II,." ...1 , "~..,oo .,. r~oIm.,1

Na+Supplementation in 2005

One group drank Rehydralyte and Pedialyte

. Two groups

• f players

were supplemented at and between meals with

• ral electrolyte

solutions

• Pickle Juice
• Rehydralyte + Pedialyte

. All subjects received

4.5g of Na+ per day

Ii. ,I.

One

group drank

Pickle juice

7

. Rapid expansion of

25

plasma volume

2.

. There were no

"

differences between ,. groups

SLIDE 8

INSTITUTE Heat"' ".'M.llo. A,ojd.."" ..d 1<oa'm..'

Blood Sodium with Supplementation

. Blood Na+was not

different between groups

. Blood Na+did not

change across days

::1

143 142

These were awesome resultsl

OR.hy .PJ

..o'h

] Nst'T;,'IT"I);'t E H..' "' ".'M."O. A,.'d ..d T'..'m..'

Na+supplementation with NO K+ in 2006 Results

I ,,"§'TI,,"/"'DT E

H.o' "' ""M.II.. A,.'d..""..d T~"m..'

. No differences

between days existed for blood Na+

. No differences

between days existed for blood K+

~

Both within normal clinical range

~ ~Ct

1

1~~100 BL Day3 D'y5 D'y11

~:~M

• p

'"m

E .

11

, 11

BL D'y3 D'y5 D'y11

[ ",r".",'t"., E H..,,".0..".'M.llo. A,ojd ..d h.'m..'

BUT- Blood Potassium was Too High!

. Blood K+was not

different between groups

. Blood K+ was elevated

from baseline (BI) to Day 5 and above normal range .,

p < 0.01 This is a BIG problem, especially for football players II

""

.PJ .Both

I N'S~1':IT';O "t " H.., m ".'M.lio. A,ojd..""..d 1<o.1m..'

~

8 ,g

~~~

"

'_.'~---='--

"

• " t:

j::~

" ." .S

..m #. Q' ,.."".

I . 'om~ ! , 00,...

Results

. PV expanded

12% by

Day 11

12 10

s,

D'Y3 D'Y5 D,y"

,."", God"5..",."IAR. Go'" JJ.""m'., ...'M',. w"9"~'""'P"""'"""gw.",",Ii".y'of<wa-'-", P""".. ",""" AmJ'parl,Mod.2005"", I ";"'TIT'UT

"

H." "' ".'M.lio.A,.'d

• od

T...Im..'

Results

. No differences

between days existed for CI- and they were within were normal clinical range

. No differences in pre-

AM or pre-PM %L':.mass

115M

B,",a;oo~

~:: ='

. .. .

• .

=~-

" " "'

.'

. . . . . '

• .

' . ' ..'

, ' , ' , ' , ' .

• .'

n

E '-, ," "

': <'i;::: .;;,

..

0.,3 0.,5 0.,11

0." 0." 0." 0." 0.,11 10: L; ! 2 . 11 .R.,. I OR.~I ...J

8

SLIDE 9

r

I l'If'g'T,"t'111' E H..' ",,... ',.'u."., A,.ld.". .,d "..Im.,.

! Individual Sodium Supplementation

I in 2007

One player received this much salt While another player received this much

~

...

\;"1 . q..

This over the counter juice contains no potassium

I~

I FB Players' Urine Color is not

I Normal and it's Heavy

!

E

H..' III,... ',.Iu.'., A,oId.noe.nd ",.'m.n'

f

Why is blood and urine K+ high?

I i' Playing football in the

I

heat causes muscle cell

death (rhabdomyolysis)

Eylerset ai, JA T 2001

. Muscle

cells have high

[K+]inside

. When cells rupture they

leak K+into the blood

. The K+has to be

excreted

I ",.;;,F'f.l*IJT E H..' ",,... ".'u.II., A,.ld.,.. .,d "..'m.,'

~

~

.

nX"

E' f;', INS'fAf'tUTE H..' ill,... ',.lu.II., A,.ld.,.. .,d "'.'moo'

'~lu

l."oo"oo'"m

". n.

s ::;

. .

.

I

~ n' ,

E ",.

,

'" ... .,

rn . .

• '"

,~ " Do" Do,' Do", Blood sodium, potassium and

chloride

were

aU perfectl

.

~

IU"-"

"m

...

s"

!::

... ..

"~nl

I:::

• '00

" " Do, 3 Do" Do",

BL D.,3 D.,5 D.,11 Better yet - the players felt great!

, NSI'IC, 'f;trT E H...iIIn... ',.lu.II., A,.ld.,.. .,d "'.'m.,'

Hyponatremia and Rhabdomyolysis

'1

00 E 30

0.,3 0.,5

"'"

This is Myoglobin

, ",.s T.Pf UTE H..'ill,...',.Ivol'.n ".Id.,.. .,d "'.'moo'

Critical Questions

. Can athletes

really become sodium

depleted?

. Does hyponatremia

always have to involve at least some ISADH?

. Why can't CE drinks

prevent hyponatremia?

. Can high sweat losses replaced with

hypotonic fluids on consecutive days causes hyponatremia? 9

SLIDE 10

E Ho""'oo.. ""'°1100 A..,do"o

• od',oolmool

FB Players Sweat Heavily

...

0 Case study in a collegiate

football player

• Average sweat losses during

practices (3days and 6 practices) =

13.5 L per day

• Maximalsweat loss =14.8

L per day

That's 35 80z glasses!!!

• Fluids consumed

during practices =

f'~kk{~,~>, S,All B,""',,,', Sw,"""" B,,1d ",m","" hy"""'"""'"

~

",

'

, m .,.'"

'

""""",, ' . ' ,

" ,,,

" "m",""" m"" Am""",, II",<b"II""Y' , " "',m,",.""."" """"O,

"" A"",""'y A,hl7'" 7hd«F """,<>(')2'".""

i, \\,\

E

• od r,oalmoo'

Sweat and Sodium Losses in NHL Players during a Pre-season Practice and a Game

• IN

S'T I'j' UTE HoaliIIoo..'.01,,°'00 ,"o'doo"" ood roeolmoo'

Introduction

0 The combination of a large BSA and equipment

results in high sweat rates, sweat losses and sodium (Na+) losses not only in games but in daily practices

Replacing large daily sweat losses with

hypotonic fluids predispose these athletes to

I

sodium dilution

0 Important

whenmultiplegamesare playedin a

I

week

~

• """"",

A

"""""."".".

n

""""",.

d

",,'

during playoffs when rinks become warmer II:::.

" ,

~ ~r

I "S't.4,;;'ttP1' E Hoa'"'00.. '.ol,afloo ,"o'doo.o aod halmoo'

Ice Hockey Players Sweat a lot

~

::..~ 'I 1 " 1 ","' , ' ,"' ,,, '

II .«,,1' . And they get hot- some

• ver 103' F

INSTJ'TUTE Ho""'oo" "0"'°'00 A.oldao.o oodholmool

Introduction

Many players in the National Hockey League (NHL) are larger than the average-sized athlete

Additionally, they exercise in a micro- environment allowing

• nly the face to be

exposed for evaporation

• f sweat.

0 The combination of a large body surface area

(BSA) and equipment may result in high sweat rates (SwR), sweat losses and sodium (Na+) losses not only in games but in daily practices.

I ".S"T"*,'!'ll" E Hool",oo.. '.°'",1100 ,"o,doo.o oodholmool

Purpose

0 To measure SwR, sweat sodium content and

total sodium losses in NHL players during a pre- season practice and compare these data to a pre-season game,

10

SLIDE 11

I

H..'III..~'~;~.;~;~:~Id~~.~'

.~~ holm..1

i Subjects

. Ten players

from the Philadelphia Flyers ,

. 4 defensemen and 6

line players

. Age = 28 :!:6 yr

• Height = 189:t

6 cm

• Mass

= 97 :t 8.5 kg

• BSA = 2.24:t

0.12 m2

~"

"

) ,

'

,,,,)

l1li.\\( Methods

. Subjects are weighed before and after the practice/game

. . Bladdervoidedpostpractice/gamefor

volumetric measurements

. All players

drank water and/or sports

drinks only from their pre-measured labeled containers

I

I

t;

'

,

SwR= (pre mass - post mass)-Uvol

+ Fluid

1

time

,

[ NS'1' [i'\J

l' E

H'"".e..E..'..H.. A." ... T~oIm..1

Sweat Analysis

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• [ !'F,S.[",.","tu

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Methods

H..IIII 0..'..11.. A." ...T~.'m..1

. Sweat data was collected

~.

during

• ne of the first pre-

season practices and then in a pre-season game the following week

. Prior to dressing

the skin

• f the right upper forearm

was prepped

. A sweat

patch was applied

~

_wen

I N'S"1' I "'iii'" ., H'" 0."""- A .od,.........

Methods

. Ambient

temperature and WBGT were recorded inside each arena next to the players' bench . Correlated t-tests were used for statistical

analysis

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r:

.----

I ,rs'1' 1-1' UTE

ResuIts

H.ot E..'..II.. A." ... ,.oatm..1

. WBGT and ambient:

temperatures were"

higher during the

:;;

game (14 and 18 .C) r:

06

versus the practice

4

(11 and 13 .C)

:

• 14= 57°F
• 18 = 64°F
• 11=52°F

~"

• 13=55°F

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11 I I I I

L

SLIDE 12

, ";\"1",.'4'04' to

H.o'III'... "°,,011°' A,oldo,oo o,d ,..oIm.n'

Results

. SwR were not

different between the

practice(1.3 :!:.3 I/hr)

and game (1.22 :!:.3 I/hr) I . Gross sweat losses

i

werehigherin the

I

game (3.7:!: 0,9 I versus 2.6 :!:0.6 I

,.;

H.o'lIIn... ',o',ollon A,oIdonoo

• nd '..oIm.,'

:~:

l.I~

.- ". ',00

:;:

.. "'--- 100 ..~ 050 0,00

G,m. I.""" ."",eo"

Results

. Sweat sodium was not different between

the practice 61 :I:31 mmol'I-1and game 67 :I:21 (range =10mmol.I-1

to 104 mmoH1)

. Players experienced greater total sodium

losses in the game (252 :I:104 versus 168 :I:118 mmol)due to higher gross sweat losses

I

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to

H.oIllln... ',o',ollon A,oldon'.

• nd "-aim.,'

What about CE Drinks?

~

. Why can't we put all of the

salt back with CE drinks?? They are actually OK for a small population

• f athletes
• Average-sized males with

average SwtR and low sweat [Na+]

• Female heavy sweaters
• Kids?????? What about the

childhood obesity epidemic?

This is non carbonated sugar and salt water

I "'sTf'TIPj' .: H.., IIIn... ',o',ollon A,oIdonooond halm.n'

Results

. Players consumed

more fluids during the game

. Body mass loss was

not different

• 1,5:!: .7% (game)
• 1.2 :!:.5% (practice)

J NS.1'.TI!)1'

"

H.oI IIIn... "o',o'on "oldonoo

• nd ho'm.n'

Results

. Mean sodium losses per

game = 5.8 9 (14.7 g NaCI or -3 tsp salt)

. Mean sodium

losses per practice = 3.9 g (9.9 g NaCI or -2 tsp salt)

. But substantial variability

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• 5000

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. 4000

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By the Numbers

. REMEMBER -All fluids that your athletes'

consume are hypotonic (not salty)

. CE drinks have Na+ - 20 mEq . L -1

. Sweat Na+ ranges

from 10- 100 mEq .L -1

. Just replacing

fluids - even with a CE drink does not adequately replace salt in heavy sweaters [Na+] <:];, "',"--~~ t-

12

SLIDE 13

I ",:,,'T'I,,"rT1T t: H.alll',." '-a'oa'a, A_alda,"" a,d T,.alm.,'

Two Examples - Sweat Studies

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How much CE is Needed? Ex. #2

. An NFL player who sweats

2.7 L .h-1and ! practices 4 h per day = 10.8 L sweat loss

I .At a sweat

Na+ content

• f 86 mEq . L-1 and

I

10.8 L per day he would lose 929 mEq or > 21 grams (21360mg) of Na+ in one day

,

. Replacing

% in food (- 5.5 tsp salt)

. He needs to consume - 24 L of CE drink

which will make him hyponatrem ic

INST"TUTE ." '_a'oallao A_alda,"" aod T,.alm.,'

nge considerably

(n=lB) LB/QB (n=12) LM (n=14) 1.42 2.0 3.15 1.11 2.25 3.14 3 2 15 48 84 23 53 99 Solt Solt Solt 12.5 .1 tsp/h 490 .25 tsp/h 589 .3 tsp/h 145 .84tsp/h 2208 1.1tsp/h 27431.4tsp/h 4085 2.1 tsp/h 5105 3.1 tsp/h 7150 3.6 tsp/h 'ow'" God" S ,," Sw..' ,O<! 'w.., oodl,m~".. t, 3 ,"'p' 0' P"""W'" ",[b", p"y'" JA'h'T~i.. A"'p'.d 10'publl""," J,'y 2009.

, NST"'t"rU" g

H.a' "'00" ho'oo'o. A_aida".

• od !,.almoo'

How much CE is Needed?

• Ex. #1

. An NHL player who sweats 2 L .h-1in a 3

hr game = 6 L of sweat loss

. At a sweat Na+ content

• f 90 mEq

L-1 and

6 L of fluid loss he would lose 540 mEq or

12.4 grams of Na + in one game

. Replacing % in food

. He needs to consume - 14 L of CE drink

which will make him hyponatrem ic

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III! \ ,\

1 N,',g,,'1'I"""1' g

H,ol"',"" '_0'00"00 A_oldo""

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What else will you get??

. Remember - we are assuming % of the

sodium is replaced with food intake

. 24 L of CE drink will likely promote

hyponatremia - AND provide:

• 4750Kcals
• ~~~ose,

fructose,sucrose)

• ~m

r;

• .

i '" .,0,. . T"".

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I Ng"T".,1'OT E

H.al"'oo" ha'oa"," A_~da'"" a,d T~o'mool

8 Yrs of Research has resulted in a Healthy, All Natural Product Line 13

I'

• ---,-

I

'.ali"o,

Sweat Na+losses ral

I

Bks Sweot Rote(L/hr) I low .43 meon 1.4, I high 2.2: Sweot No' (mol/L) low 22.'

I

meon so i high 80 i No' loss(mg/hr)

, low 22 meon 16

.. .

SLIDE 14

• [ 1'1""'1"')""1'01'

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Tea H2O Results

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Salt/volume depletion

Illness

. Should

not be classified as a Heat illness

• Caused by low serum Na+but may not clinically

be classified as hyponatremia until Na+::; 130 mmol"I-1«135 mmol"I-1is better)

• Usually occurs in athletes who sweat heavily
• ver several consecutive days
• Waterlossis replacedbut Na+is not
• Does not involve hyperthermia
• Athlete is hypovolemic

1 N..,'F1",..4'{J 'I' I< '00' "'"0" ""O""" A"I',"o. '"' ',oo'm."'

Management

. Rest - Do not let them play

. Administer

high electrolyte drink orally

. Consider

IV fluid replacement (saline)

. Monitor vital signs (blood

pressure)

. Recovery

usually within 24 hours

. Educate

athletes about replacement

• f

electrolytes (salt food liberally)

~

~ II!! .hi

1 NST+1"IJ"1" >: '001 "'"... ""001'," A,,!d,"," ,"d '..,'mo"'

What is Heat Exhaustion?

.Water depletion

• Symptomatic

dehydration

• Caused

by inadequate replacement

• f water

losses (dehydration beyond 3 - 4%)

• Beginning a second bout of exercise

hypohydrated

• Untreated it can lead to heat stroke
• Involves an elevated core temperature

I NiS"1'11'1)'. I< '00' "'"0" ""0,11°" A,~do"oo ,"d ,..,1m.",

Signs and Symptoms of SalWolume DepletionIllness

. Weakness . Fatigue . Severe headache

. Muscle aches

.Anorexia

. Nausea

. Vomiting

. Diarrhea

. Pale, clammy skin

. Low BP

. Tachycardia

. Syncope

. Normal

• r low body

temperature ** The athlete feels "sick" Thisillness isprobably under diagnosedor misdiagnosed asa viralillness

• rfoodpOISoning

1 l'FS"T'."FlJ1' I< '00' "'"... ""O"'O" A,~d,"oo ,"d ,..,lme"'

Prevention

, It is caused by consecutive days of large

daily Na+losses not replaced and drinking too much of anything

. Knowyour athletes' sweat rate

. Knowyour salty sweaters

. Swt [Na+]and SwtR are extremely variable

. We have to get rid of consecutive days of

two-a-day practices!!

14

SLIDE 15

, N',ST+'WTI 'I' t:

Heal ""O" halaalla, A,~da"e a,d ".almo,1 I Prevention

. e Knowyourathletes who

are hypertensive

• Be aware of which

athletes are on a low Na++ diet

• Be aware of athletes on

ACE inhibitors

• Medication may need to

be altered during preseason

, N """I' . 'I''u T E

Heal ""O" halaaha, A,alda,"" a,d T,ealmo,1

Prevention

e REMEMBER

• 2 - 3 %dehydration

isOK

I

e

Hypohydration prior to practice is not - are they

I

gainingwt back?

e Replacelostelectrolytes

. 4 meals per day of

sodium rich foods and fluids

. NaGI supplementation ~

, NS1'

"1'0'1' E

Hoal "',e.. "0100100' A'alda"o a,d healmo,l

Prevention

. N'ST""'ftP1' t:

Heal ""O" ',alaalla, A'alda"e a,d T,.almo,' e Require weight charts

and monitor them

e Be aware of athletes

who cannot maintain body weight

e Thinkbeyond pre-

season fallsports

~ ;,,\'1,.'1

Their issues occur more often in post-season playoffs

1 N..S"1' 11'&1' E

4 meals per"'daya'(jua;lnOg'dpre':Season (football) and Playoffs (hockev)!

• Eat foods high in Na+

and Mg++and CL-

• Avoid too much

potassium in these populations-

• Can consume some

Pedialyteor PJ

.2-3 bottles pedialyte

.3-4 OZ PJ

IiW(I: .

Breakfast Foods

. N"S'T.!,"I"(JT E Hoa'"',e.. "0100110'"alda"e a,d ha'me,1

e

Cereals

• Chex cereal
• Golden grahams
• Maple and brown

sugar oatmeal

• Rice krispies
• Total
• Frosted wheaties
• Basic 4

e Breads

• Corn muffins
• Bagels
• Whole wheat

English muffins

e Meats

• Sausage
• Canadian bacon
• Ham

15

SLIDE 16

I ""g"T""'I'IJ'I' E H.allII,... ",01"°11°'A.o"ooo. 00' ',.alm.,'

Lunch and dinner foods

• Hotdogs and Lunch meats
• Soups

.Chicken

noodle

. Onion

.Vegetable

. Tomato

. Cream

• f chicken
• r

mushroom

. NE Clam Chowder

. Chicken gumbo

lF1

' . Splitpea and ham

11my\,

• Sauerkraut
• Cheese

.American

.cottage

. Parmesan

• Pizza
• Tomatoes
• Salads withdressing

.zestyItalian

. French

. Caesar

I N S;,;fIT'IF't "

Drinks anOd'.S.~ack'so.

00' f'..'m.,'

• Snacks

. Pickles

. Pretzels/chips . Cheese

puffs

. Chex mix

• Drinks

. Tomatojuice . V-8 juice . Pedialyte . Pickle juice

• I ""S1',"Jj'OT

"

H.o' III ",0'"°11°' A.old.,oo 00' Tmalm.,1

How much CE is Needed?

• Ex. #1

. A football

player who sweats 3.5 L .h-1and

practices 4.5 h per day = 13.5 L sweat loss

. At a sweat Na+ content

• f 50 mEq .L-1 and

13.5 L per day he would lose 675 mEq or 15.5 grams of Na+ in one day

i . Replacing % in food (4 tsp salt) ! . He needs to consume - 17 L of CE drink

. Won't this promote sodium dilution? Yes!

I "'if-"","'!U"

E H..IIII ",0'"°11°' Mold.". ." T'..'m.,'

Lunch and dinner foods

• Sauces

.Marinara .Alfredo sauces

.Beeformushroom

gravy

• Stir-fry

.teriyaki and soy

sauces

. Chili, stews . Chow mein vegetables . Navy beans, chick peas, baked beans . Peas and carrots . Pita bread

INS f 1'1' IJ T " H..IIII,...E..'".'., A..ldo,oo." halm..'

Foods to avoid during pre-season

Orange juice

Bananas

Dried fruits Baked potatoes

. Raisins

. Nuts

. Spinach

. Mushrooms . Lima beans . Black beans

. Lentils

. Cucumbers . Squash . Zucchini . Brussel sprouts

. Gatorade

Endurance Ie

16