CONSENSUS STATEMENT

Association of Physicians of India Expert Recommendations

on Oral Fluid, Electrolytes, and Energy Management during
Transition Care and Discharge for Hospitalized Patients with
Nondiarrheal Illnesses
B Ravinder Reddy1, L Sreenivasamurthy2, Jyotirmoy Pal3 , Sanjith Saseedharan4 , Prachee Sathe5 , Anuj Maheshwari6 , Eileen Canday7,
Babita G Hazarika8, Amol Patil9*, Harshad Malve10, Priti Thakor11
Received: 25 April 2024; Accepted: 08 May 2024

A b s t r ac t conditions are not carefully monitored and

treated, they can lead to shock, especially in
Acute nondiarrheal illnesses (NDIs) involve overt or subclinical dehydration, requiring rehydration
and electrolyte repletion. Dehydration is frequently under-recognized and under-managed, both those with dengue hemorrhagic fever.12
in outpatient departments (OPDs) and inpatient departments (IPDs). Postadmission dehydration The elderly, constituting a major portion
is associated with longer hospital stays and higher inhospital mortality rates. Recognizing and of hospital inpatients, face an increased risk
understanding dehydration in hospitalized patients is necessary due to the adverse outcomes of dehydration—a significant health concern
associated with this condition. In this article, we aimed to develop practical consensus ranking among the top ten reasons for their
recommendations on the role of oral fluid, electrolyte, and energy (FEE) management in hospitalized hospitalization.5,13 In the elderly, dehydration
patients with FEE deficits in NDI. The modified Delphi consensus methodology was utilized to reach affects 20–30% of cases. Compared to
a consensus. A scientific committee comprising eight experts from India formed the panel. Relevant younger individuals, dehydration has a more
clinical questions within three major domains were formulated for presentation and discussion: detrimental effect on the geriatric population
(1) burden and factors contributing to dehydration in hospitalized patients; (2) assessment of
and is associated with higher mortality,
fluid and electrolyte losses and increased energy requirements in hospitalized patients; and (3)
management of FEE deficits in hospitalized patients [at admission, during intravenous (IV) therapy, morbidity, and disability risks.14 In a prospective
IV to oral de-escalation, and discharge]. The consensus level was classified into agreement (mean study conducted by a prominent hospital in the
score ≥4), no consensus (mean score <4), and exclusion (mean score <4 after the third round of United Kingdom (UK), 37% of admitted patients
discussion). The questions that lacked agreement were discussed during the virtual meeting. The over the age of 65 years were dehydrated.15
experts agreed that the most common factors contributing to dehydration in patients with NDI This is because older adults often take
hospitalized in IPDs include decreased oral fluid intake, increased fluid loss due to the illness, medications that can cause dehydration and
insensible fluid loss, and a lack of awareness among doctors about dehydration, which can result in may experience reduced kidney function
poor fluid intake. Time constraints, discontinuity of care, lack of awareness of the principles of fluid
balance, lack of formal procedures for enforcing hydration schemes, and lack of adequate training 1
Senior Consultant, Division of Surgical
are most often barriers to the assessment of hydration status in hospital settings. Experts used Gastroenterology, Care Hospital - The Institute
hydration biomarkers, such as changes in body weight, serum, or plasma osmolality; fluid intake; of Medical Sciences, Hyderabad, Telangana;
and fluid balance charts; along with urine output, frequency, quantity, and color, to determine 2
Senior Consultant Physician & Medical Director,
hydration status in hospital settings. Experts agreed that appropriate FEE supplementation in the Department of Medicine, Life Care Hospital and
form of ready-to-drink (RTD) fluids can restore FEE deficits and shorten the length of hospital stays Research Centre, Bengaluru, Karnataka; 3Professor,
in hospitalized patients at admission, during de-escalation from IV to oral therapy, and at discharge. Department of General Medicine, R G Kar Medical
RTD electrolyte solutions with known concentrations of electrolytes and energy are good choices to College and Hospital, Kolkata, West Bengal; 4Head
avoid taste fatigue and replenish FEE in hospitalized patients during transition care and at discharge. of Department, Critical Care, S L Raheja Hospital,
Mumbai; 5Director, Department of Critical Care
Journal of the Association of Physicians of India (2024): 10.59556/japi.72.0571 Medicine, Ruby Hall Clinic, Pune, Maharashtra;
6
Professor, Department of General Medicine,
Hind Institute of Medical Sciences, Lucknow,
Introduction hypotension, poor glycemic control, and Uttar Pradesh; 7Head of Department, Department
thromboembolic events, such as coronary
In clinical contexts, the term “dehydration” is of Nutrition and Dietetics, Sir H N Reliance
heart disease and stroke.5,7 Diabetes mellitus Foundation Hospital and Research Centre,
used to describe a lack of total body water. (DM) is also associated with an increased Mumbai, Maharashtra; 8Head of Department,
Dehydration is common and financially incidence of electrolyte abnormalities as Department of Dietetics, Apollo Multispecialty
burdensome in healthcare environments.1 a result of variables such as reduced renal Hospitals, Kolkata, West Bengal; 9Medical Lead;
Dehydration stems from the depletion of function, malabsorption syndromes, acid-
10
Therapy Area Head (Self Care); 11Head of Medical
essential water necessary for normal bodily base problems, and multidrug regimens. 8 Affairs, Southern Asia, Medical Affairs, JNTL
processes.2,3–5 The major routes of water loss Furthermore, a low daily total water intake Consumer Health (India) Private Limited, Mumbai,
are through urine, stool, perspiration, and Maharashtra, India; *Corresponding Author
is associated with a higher diagnosis of
insensible water loss by evaporation from hyperglycemia. 9 Hyperglycemia caused How to cite this article: Reddy BR,
the respiratory system and diffusion through Sreenivasamurthy L, Pal J, et al. Association of
by stress is reported in severely ill patients
Physicians of India Expert Recommendations
the skin.4,6 Dehydration is often overlooked during hospitalization.10,11 According to a on Oral Fluid, Electrolytes, and Energy
and inadequately addressed in both hospital study conducted in Central America, dengue Management during Transition Care and
and community-based care settings.1 Patients patients were reported to be more likely to Discharge for Hospitalized Patients with
who are dehydrated are more likely to be dehydrated due to high fever, vomiting, Nondiarrheal Illnesses. J Assoc Physicians India
develop kidney stones, pressure ulcers, diarrhea, and associated anorexia. If these 2024;72(6):57–66.

© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/
by-nc/4.0/). Please refer to the link for more details.
 Association of Physicians of India Expert Recommendations on Oral FEE
and difficulty regulating fluid balance due
to aging or health issues.13 Additionally,
they may lose fluids because of age-related
factors such as decreased muscle mass and a
lower percentage of total body water.13 In a
retrospective study conducted in a hospital
setting, out of 2,591 registered patients, 1,606
(62%) experienced dehydration at some stage
of their admission. Factors independently
linked to dehydration comprised older age,
female gender, total anterior circulation
syndrome, and the prescription of diuretics.16 In
a systematic review, it was found that patients
experiencing dehydration exhibited elevated
mortality rates. The length of hospital stays,
whether categorized as a primary or secondary
diagnosis, is prolonged in individuals with
dehydration compared to those who are
adequately hydrated.17 A study by Edmonds
et al. highlighted that dehydration may have an
impact on neurocognitive functioning.17 Acute
illnesses in children can lead to fluid imbalances
and varying levels of hypovolemia and
dehydration, which can be life-threatening.18,19
Heat-related illness (HRI) encompasses a range
of clinical disorders arising from exposure
to extreme environmental heat and the
body’s insufficient regulation of heat.18,20 If
left untreated, dehydration can contribute to
three distinct types of HRI—heat cramps, heat
exhaustion, and heat stroke.18,21
The standard treatment for dehydration
typically involves restoring lost body fluids
through oral or enteral intake and, in severe
cases, intravenous (IV) fluid replacement.
In acute nondiarrheal illnesses (NDIs), both
apparent and hidden dehydration may develop,
underscoring the importance of rehydration
and electrolyte replenishment.18 Recognizing
and understanding dehydration in hospitalized
patients is necessary due to the adverse
outcomes associated with this condition. In this
article, we have summarized expert opinions
and recommendations on (1) the burden
and factors contributing to dehydration in
Fig. 1: Overview of the consensus process used to develop the clinical consensus statement
58 Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024)
hospitalized patients, (2) methods and barriers •
to the assessment of hydration status in
hospital settings, and (3) the management of •
fluid, electrolyte, and energy (FEE) deficits in
hospitalized patients. We formulated consensus
statements for the management of oral FEE •
deficits during transition care and discharge in
hospitalized patients.
M at e r ia l s and Methods
Panel Selection
A panel of eight experts (Fig. 1) was chosen
based on their academic achievements,
participation in clinical research, and diverse
experiences from different parts of the
country. A chair was identified to drive the
consensus process.
Evidence Review
A comprehensive electronic search was
conducted on the PubMed/MEDLINE database
to identify pertinent articles published from
January 2000 to July 2023, using diverse
keyword combinations, including “electrolytes,”
“oral fluids,” “fluids,” “dehydration,” “energy,”
“nondiarrheal illnesses,” “burden,” “assessment,”
“management,” and “oral rehydration” along
with appropriate variations in search phrases
and Boolean operators (AND, OR). The included
sources comprised randomized controlled
trials, case reports, practice guidelines,
consensus recommendations, sur veys,
systematic literature reviews, and meta-
analyses. Research studies involving animals
or published in a language other than English
were excluded. Replicates were eliminated
during the filtering process.
Development of Questionnaire
After an extensive search, a total of 90 clinically
relevant questions and/or statements were
drafted to facilitate the discussion. A modified
Delphi consensus was considered to arrive at Adapted from: Rüetschi and Salazar, 2022;23
a consensus.22 The questionnaire was divided Rüetschi and Olarte Salazar, 2020;24 Burgess Kelle-
into three major domains:
Burden of dehydration in hospitalized
patients.
Assessment of fluid and electrolyte losses
and increased energy requirements in
hospitalized patients.
Addressing FEE deficits in hospitalized
patients (at admission and during IV
therapy, IV to oral de-escalation, and
discharge).
Cer tain open- ended and sur vey-t ype
questions were incorporated to gather
valuable insights from experts on the three
broad objectives. An electronic survey
link to these questions was sent to all the
participants to record their views (Delphi
survey—round 1).
Consensus Process
The level of consensus ( Table 1) was
categorized as agreement (mean or average
score is ≥4 on the 5-point Likert scale), no
consensus (mean or average score is <4
on the 5-point Likert scale), and exclusion
(mean/average score is <4 on the 5-point
Liker t scale af ter three rounds). 23–26 A
virtual meeting was conducted to review
the round 1 Delphi survey results, open-
ended questions, and statements that did
not attain consensus during the Delphi
Table 1: Level of consensus
Level of Definition
consensus
Agreement Mean/average score is ≥4 on the
5-point Likert scale
No Mean/average score is <4 on the
consensus 5-point Likert scale
Exclusion After three rounds, if the mean/
average score is <4 on the 5-point
Likert scale, the statement is
excluded
her et al., 2020;25 Galipeau et al. 201726
 Association of Physicians of India Expert Recommendations on Oral FEE

sur vey round 1. A round 2 sur vey was losses.29 In short-term and prolonged illness, particularly in older patients. 34 In other
conducted to discuss questions/statements various factors can lead to insufficient fluid types of acute NDI, there might be a need
that did not achieve consensus during the intake, causing dehydration. 27 Older adults for additional energy due to the body’s
first round of discussion. The consensus frequently take multiple medications with hypermetabolic response, and patients
report was drafted based on the meeting dehydrating side effects, and their ability to may also experience an LOA during these
o utco m es an d th e f inal dr af t of th e regulate fluid balance may decrease due to illnesses. 36 Therefore, using usual WHO
consensus was emailed to all the experts normal aging or health issues.13,30 Additionally, oral rehydration solution (ORS) for NDI may
for their opinion. increased fluid loss is a common part of the be insufficient and could create a gap in
aging process.13,30 A significant number of dehydration management.36
older adults do not drink enough fluids.13,30 In Fluid, electrolyte, and energy disorders
R e s u lts a study of 188 residents in UK care homes, 20% are prevalent among patients of all ages18,36
Following the results of the literature search, were dehydrated, and an additional 28% were and patients often experience electrolyte
90 clinically relevant questions and/or on the verge of dehydration.31 This is often imbalances. 36 Hospitalized individuals are
statements [open-ended and survey-type due to a reduced sense of thirst; some people at a higher risk of developing combined
(N = 26); statements (N = 64)] were developed also avoid drinking due to fear of incontinence electrolyte disorders, which can lead to
and included in the Delphi survey. Of the 64 and the need for more frequent bathroom decreased serum levels of potassium (K+),
statements, 60 reached consensus (mean visits.29,32,33 sodium (Na+), calcium (Ca2+), and chloride
score ≥4) in the round 1 survey, and four (C l − ) . 3 7 H y p e r o s m o l a r d e h y d r a t i o n ,
reached consensus during the round 2 survey Expert’s opinion: factors contributing to specifically, is common among older adults
(Table 2). dehydration in hospitalized patients in hospitals and is linked to poor outcomes. 38
• The most common factors contributing to A pilot study involving 33 patients at the
Discussion dehydration in patients hospitalized for Chelsea and Westminster Hospital in the UK
NDIs include decreased oral fluid intake, found that a notable number of patients were
Burden of Dehydration in increased fluid loss due to the illness, reported to be dehydrated upon admission,
Hospitalized Patients insensible fluid loss, and a lack of awareness and only a few had their hydration needs
Dehydration encompasses a diverse range of among doctors about dehydration, which addressed. 5 In a study at a UK teaching
conditions, each exhibiting distinct clinical can result in poor fluid intake
hospital with 200 participants, 37% were
and biochemical presentations.1 Literature • The lack of awareness among doctors is a
crucial contributing factor to dehydration,
found to be dehydrated at admission. Of
indicates that the burden of dehydration can those, 62% remained dehydrated after
especially in post-intensive care unit (ICU)
vary between 30% and 70%.15,27 Dehydration 48 hours.15 In 1991, a retrospective study
settings
can manifest as hypotonic, hypertonic, or examined 160 adult cases of inhospital
• Resident medical officers (RMOs) lack
isotonic (Table 3).1,28 patience, training, time, and prioritization hypernatremia (>150 mmol/L) within a health
for dehydration assessment. When district for a single year. The study revealed
Expert’s opinion: burden of dehydration administering IV therapy, medical staff that 60% of the cases were newly diagnosed
(treating physicians, nurses) often neglect and occurred during the hospital stay. 39
• In this study, approximately 50% of the
to administer recommended portions of Fluid and electrolyte imbalances in critically
experts (n = 4) agreed that 50 – 69%
oral fluids. Furthermore, fluid consumption ill patients can have fatal consequences. 37
of hospitalized patients experience
from outside sources is sometimes restricted
dehydration, and among these dehydrated It is crucial to be especially cautious about
for patients, possibly further contributing to
patients, 30–49% are diagnosed with electrolyte disturbances in intensive care, as
dehydration. Most often, fluid administered
hypertonic dehydration assessing the signs and symptoms of critically
during the recovery stage does not intend to
• Hypotonic dehydration, often attributed to ill patients can be challenging.37 In a study by
address dehydration or is not administered in
the use of diuretics, which results in greater El-Sharkawy et al., it was found that the risk
proper amounts. This may further contribute
sodium loss than water loss, is observed
to dehydration of fatality is six times more in patients facing
in 5–14% of hospitalized patients with
• Other variables that contribute to dehydration dehydration in the hospital.15 Dehydration
dehydration
• Three out of eight experts (38%) believed include decreased oral fluid intake, increased is strongly connected to the onset of acute
that 30–49% of hospitalized dehydrated fluid loss owing to illness, and a lack of day- kidney injury (AKI), and around 25% of
patients exhibit isotonic dehydration to-day fluid balance monitoring patients who experience hospital-acquired
dehydration develop AKI.38 Dehydration not
only affects patients’ stay in the hospital but
Factors Contributing to Dehydration Postadmission Dehydration and also leads to financial burdens for the National
in Hospitalized Patients Fluid, Electrolyte, and Energy Deficits Health Service (NHS).40 Those who experience
Fluid loss can b e cause d by various in Hospitalized Patients hospital-acquired dehydration stay in the
pathophysiological reasons or a reduction Hospitalized patients with NDI of ten hospital, on average, 3 days longer and face a
in oral fluid intake. 29 Common causes e xp erience a loss of app etite (LOA), higher risk of a failed discharge.15
of dehydration in nondiarrheal patients anorexia, and an increased demand for E x p e r t a d v is o r y co m m i t te e s a n d
hospitalized in inpatient departments (IPDs) energy. 34,35 LOA is common in both older international guidelines have emphasized
include decreased oral fluid intake, increased and younger patients.34 Inadequate nutrition dehydration as an independent risk factor
fluid loss, insensible fluid loss, and lack of can cause nutritional deficiencies, leading for thrombosis development. 41 Water
doctor awareness, leading to poor fluid to malnutrition or undernutrition. 34 This is a key part of blood, and dehydration
intake.1,4 Conditions such as excessive sweating results in compromised immunity, increased lowers the body’s blood volume. 42 This
and fevers can also lead to increased fluid vulnerability to infections, and weight loss, negatively affects the delivery of oxygen

Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024) 59

 Association of Physicians of India Expert Recommendations on Oral FEE

Table 2: A summary of consensus statements

Consensus statements Mean score (round 1) Mean score (round 2)
No Burden of dehydration and FEE deficits in hospitalized patients
1 The prevalence of dehydration is high in hospitalized patients; however, it is not readily detected 4.63 NA
2 Hyponatremia is the most common electrolyte abnormality encountered in hospitalized 4.38 NA
patients
3 LOA is reported in hospitalized patients with NDI 4.63 NA
4 Anorexia and increased energy demand are common in hospitalized patients 5.00 NA
5 More than 50% of hospitalized patients have a combination of FEE deficits at admission 4.13 NA
6 Elderly patients have higher chances of dehydration at hospital admissions or during their stay 4.63 NA
in hospital
7 There is an increased risk of FEE deficits in hospitalized patients during de-escalation from IV to 4.50 NA
oral therapy
8 The probability that patients continue to have FEE deficits after discharge from the hospital 4.00 NA
is high
9 FEE deficits secondary to inadequate oral fluid intake and inadequate calorie supplementation 4.13 NA
lead to poor outcomes, including increased risk of mortality in hospitalized patients
10 FEE deficits in hospitalized patients at discharge have a high impact on their recovery 4.25 NA
11 The impact of FEE deficits on clinical outcomes in hospitalized patients, resulting in prolonged 4.13 NA
bed days and failed discharges, is quite high
12 FEE deficits in hospitalized patients have a high impact on clinical outcomes, resulting in 4.50 NA
prolonged bed days and failed discharges
13 Postadmission FEE deficits in hospitalized patients can lead to risks for thromboembolic events 4.50 NA
14 Postadmission FEE deficits in hospitalized patients can lead to risks for impaired wound healing 4.50 NA
15 Postadmission FEE deficits in hospitalized patients can lead to risks for pressure ulcers 4.63 NA
16 Postadmission FEE deficits in hospitalized patients can lead to risks for anorexia 4.13 NA
17 In hospitalized patients, irrespective of the cause of admission, uncorrected FEE deficits can 4.14
lead to hypotension
The statement was modified, and consensus was achieved in round 2
18 In hospitalized patients, irrespective of the cause of admission, uncorrected FEE deficits can 4.00
lead to poor glycemic control
The statement was modified, and consensus was achieved in round 2
19 In hospitalized patients, irrespective of the cause of admission, uncorrected FEE deficits can 4.28
lead to the risk of falls
The statement was modified, and consensus was achieved in round 2
20 FEE deficits in hospitalized patients have a high impact on their recovery 4.63 NA
21 Homemade fluids, such as dal water, rice kanji, and lime juice/fruit juices may not be enough to 4.00 NA
address FEE deficits in hospitalized patients during de-escalation from IV to oral therapy
Assessment of fluid and electrolyte losses and increased energy requirements in hospitalized patients
22 All patients above the age of 60 should be screened for low-intake dehydration at the first 4.63 NA
opportunity
23 Hydration is an important parameter to be considered for the recovery of hospitalized patients 4.63 NA
24 Routine assessment and management of patients’ FEE needs as a part of ward rounds is essential 4.88 NA
25 Healthcare professionals should ask for the frequency and magnitude of fever/other reasons 4.75 NA
during rounds to assess the insensible losses in addition to the intake/output chart
26 It is important to assess the level of dehydration in patients hospitalized for NDI and monitor 4.75 NA
the need for rehydration along with energy needs at admission on day 1
27 It is important to assess the level of dehydration in patients hospitalized for NDI and monitor 4.38 NA
the need for rehydration along with energy needs during IV therapy
28 It is important to assess the level of dehydration in patients hospitalized for NDI and monitor 4.75 NA
the need for rehydration along with energy needs during de-escalation from IV to oral
29 It is important to assess the level of dehydration in patients hospitalized for NDI and monitor 4.50 NA
the need for rehydration along with energy needs at discharge
Addressing FEE deficits in hospitalized patients
30 Oral FEE should form a part of core treatment from day 1 in hospitalized patient 4.25 NA
 Contd…

60 Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024)

 Association of Physicians of India Expert Recommendations on Oral FEE

Contd…
Consensus statements Mean score (round 1) Mean score (round 2)
31 For hospitalized patients able to tolerate oral fluids, a mix of IV fluids and oral fluids with 4.50 NA
electrolytes and energy may be considered an efficient FEE replenishment method
32 Oral FEE should form a part of core treatment in hospitalized patients during de-escalation 4.50 NA
from IV to oral therapy
33 Oral FEE should form a part of core treatment in hospitalized patients at the time of discharge 4.50 NA
34 Oral FEE restoration is vital for the recovery of hospitalized patients at admission 4.50 NA
35 Oral FEE restoration is vital for the recovery of hospitalized patients during de-escalation from 4.50 NA
IV to oral therapy
36 Oral FEE restoration is vital for the recovery of hospitalized patients at discharge 4.63 NA
37 Appropriate FEE supplementation in the form of RTD fluids can restore FEE deficits and shorten 4.50 NA
the length of hospital stays in hospitalized patients at admission
38 Appropriate FEE supplementation in the form of RTD fluids can restore FEE deficits and shorten 4.63 NA
the length of hospital stays in hospitalized patients during de-escalation from IV to oral therapy
39 Appropriate FEE supplementation in the form of RTD fluids can restore FEE deficits and shorten 4.38 NA
the length of hospital stays in hospitalized patients at discharge
40 Written recommendations of RTD oral fluids with known concentrations of electrolytes and 4.38 NA
energy for de-escalation facilitate faster recovery vs. relying on homemade foods and fluids
41 Written recommendation of RTD oral fluids with known concentrations of electrolytes and 4.50 NA
energy at discharge can facilitate enhanced patient recovery at home
42 FEE deficits in hospitalized patients need to be replenished with energy and electrolytes along 4.63 NA
with fluids
43 Among oral fluids, RTD oral fluids with known concentrations of electrolytes and energy can 4.13 NA
have a superior impact on recovery compared to homemade fluids
44 FEE deficits in hospitalized patients need to be replenished with energy and electrolytes along 4.38 NA
with fluids
45 Oral fluid and electrolyte formulations should have adequate energy content to meet increased 4.50 NA
caloric, metabolic, and nutritional demands in hospitalized patients with NDI
46 The timely introduction of oral fluids to hospitalized patients improves the speed of recovery 4.63 NA
47 RTD FEE drinks improve the speed of recovery in hospitalized patients 4.25 NA
48 RTD FEE electrolyte drinks improve the speed of recovery during de-escalation from IV to oral 4.38 NA
fluids/nutrition
49 RTD FEE electrolyte drinks with known concentrations of electrolytes and energy are 4.38 NA
recommended at the time of discharge of hospitalized patients to improve their speed of
recovery
50 FEE should be specified as a written recommendation to patients, just like other 4.50 NA
pharmacological prescriptions
51 RTD electrolyte solutions with known concentrations of electrolytes and energy are good 4.50 NA
choices to avoid taste fatigue and replenish FEE in hospitalized patients, including during IV to
oral de-escalation and at discharge
52 Coconut water may not be adequate for hospitalized patients (except those with hypokalemia) 4.38 NA
due to variable sodium and glucose content and high potassium content
53 Plain water should not be recommended as the sole source of hydration for addressing fluid 4.63 NA
and electrolyte deficits in hospitalized patients
54 Carbonated beverages and fizzy energy drinks should not be recommended in hospitalized 4.88 NA
patients
55 Calorie details or energy should be co-packaged in oral fluid and electrolyte formulations 4.75 NA
56 FEE management is applicable and relevant as an adjuvant in hospitalized patients (various 4.50 NA
patient profiles) to facilitate speed of recovery
57 Written RTD FEE recommendations should be given at the time of discharge of hospitalized 4.50 NA
patients to facilitate speed of recovery
58 RTD FEE formats with known concentrations of electrolytes and energy as adjuvants can 4.75 NA
facilitate faster recovery in the elderly
59 RTD FEE formats with known concentrations of electrolytes and energy as adjuvants can 4.38 NA
facilitate faster recovery in patients with diabetes
 Contd…

Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024) 61

 Association of Physicians of India Expert Recommendations on Oral FEE

Contd…
Consensus statements Mean score (round 1) Mean score (round 2)
60 RTD FEE formats with known concentrations of electrolytes and energy as adjuvants can 4.25 NA
facilitate faster recovery in longstanding hospitalizations for cerebrovascular accidents, COPD,
and pyrexia of unknown origin
61 RTD FEE formats with known concentrations of electrolytes and energy as adjuvants can 4.13 NA
facilitate faster recovery in infectious NDI
62 RTD FEE formats with known concentrations of electrolytes and energy as adjuvants can 4.38 NA
facilitate faster recovery in patients with inadequate food intake
63 RTD FEE formats should be preferred to address FEE deficits in hospitalized patients with 4.38 NA
medical illnesses
64 Scientifically formulated RTD formats (electrolyte drinks) are adjuvant to reduce the need for 3.75 4.43
supplementary IV therapy in hospitalized patients who can tolerate oral fluids
All the statements apply to hospitalized patients with medical illnesses or conditions (nondiarrheal only) and for addressing their FEE deficits unless specifically
contraindicated basis clinical scenario or clinician’s perspective. This does not include surgical patients in its scope of discussion; COPD, chronic obstructive
pulmonary disease; FEE, fluid, electrolyte, and energy; IV, intravenous; NDI, nondiarrheal illnesses; RTD, ready-to–drink

Table 3: Definitions of hypotonic, hypertonic, and isotonic dehydration
Hypotonic dehydration
Hypertonic dehydration
Isotonic dehydration
Hypotonic dehydration primarily arises from the use of diuretics,
which results in a greater excretion of sodium compared to water.
Hypotonic dehydration is defined by a decrease in sodium levels
and osmolality1,28
Hypertonic dehydration is characterized by a situation where the
amount of water lost from the body is greater than the amount
of sodium lost. Hypertonic dehydration consistently results in
increased levels of serum sodium and osmolality. Some examples
of hypertonic dehydration include fever, elevated respiration, and
diabetes insipidus1,28
Isotonic dehydration refers to a state when there is a
proportionate loss of both water and sodium while the
concentration of sodium in the blood remains within the
normal range, maintaining the normal osmolality of the blood
serum. The volume of intracellular fluid remains unchanged,
while there is a decrease in the volume of extracellular
fluid. Reasons for isotonic water loss include vomiting,
perspiration, burns, intrinsic renal disease, hyperglycemia, and
hypoaldosteronism1,28
Assessment of Fluid and Electrolyte
Losses and Increased Energy
Requirements in Hospitalized Patients
Methods of Hydration Status Assessment
Measuring hydration status is challenging
due to the complex dynamics of fluid
regulation. Clinically, dehydration is often
diagnosed using blood and urine markers,
along with physical signs and symptoms. 52
A review comparing noninvasive methods
(use of minimally invasive clinical symptoms,
signs, or tests to screen for water loss and
dehydration in older adults) in older people
found that none were reliable compared
to serum osmolality. 52,53 Blood indices may
not accurately show changes in fluid status,
and urine markers could be more suitable.47
Different markers may be appropriate for
different groups as they reflect different types
of dehydration.52

and nutrients to wounds, thereby affecting
the healing process. 42 As water carries
nutrients to and from cells, its loss hampers
this transpor t system, disrupting cell
function. 42 Even mild dehydration can
lead to fatigue, headaches, dry mouth and
tongue, lethargy, muscle weakness, light-
headedness, dizziness, and a lack of focus. 2
Severe dehydration can lead to hypotension
and, in extreme cases, loss of consciousness.2
Limited literature supports a direct link
b e t w e e n d e hy d r a t i o n a n d g l y c a t e d
hemoglobin (HbA1c) levels. However, an
increase in urea due to dehydration can
impact HbA1c test results, depending on the
assay used.43,44 Additionally, 3 days of low
water intake in patients with diabetes can
acutely affect blood glucose response.7 In
addition, patients who are dehydrated for an
additional day are twice as likely to develop
delirium compared to those who did not
experience dehydration.7,45 Multiple studies
have reported the association between
dehydration and hypotension, poor glycemic
control, risk of falling, thromboembolism,
impaired wound healing, pressure ulcers,
and anorexia. 5,45–51
In this study, the experts agreed that
uncorrected FEE deficits in hospitalized
patients, irrespective of the cause for
admission, can lead to hypotension, poor
glycemic control, and risk of falls. Additionally,
postadmission FEE deficits in hospitalized
patients can lead to risks for thromboembolic
events, impaired wound healing, pressure
ulcers, and anorexia. The experts also agreed
that FEE deficits in hospitalized patients have
a high impact on clinical outcomes resulting
in prolonged hospitalization and failed
discharges.
Expert’s opinion: hydration markers most
commonly used to determine hydration status
in hospital settings
• Changes in body weight
• Fluid intake
• Fluid balance charts
• Urine output/quantity
• Urinary void frequency
• Urine color
• Clinical signs and symptoms
• Serum/plasma osmolality
• Urine osmolality
Barriers to the Assessment of Hydration
Status in Hospital Settings
Several barriers exist for the assessment
of hydration s tatus. In a small -scale
investigation conducted by Jeyapala et al.,
the fluid balance charts in an acute hospital
setting were assessed and found to be

62 Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024)

 Association of Physicians of India Expert Recommendations on Oral FEE
inaccurately completed. 54 Some charts
had missing data, while others contained
inappropriate comments (e.g., instances
where measurements were forgotten). The
authors identified barriers to accurate chart
completion, including factors such as a
lack of time, training, communication, and
accountability. 54 Additionally, they noted
that certain wards lacked the necessary
equipment for precise fluid measurements.
It is worth noting that these balance charts
only account for urine and gastrointestinal
output, overlooking other potential water
losses from lungs to sweat. As a result, they
may underestimate total fluid excretion.54
Expert’s opinion: barriers to the assessment of
hydration status in hospital settings
• The experts agreed that time constraints,
low priority given to hydration status,
lack of formal procedures for enforcing
hydration schemes, lack of awareness
and education on the importance of fluid
status, and discontinuity of care are the
most common barriers to the assessment of
hydration status in hospital settings
• Currently, various nutrition tools are used to
assess malnutrition, but there is no specific
tool for evaluating dehydration. Typically,
a general assessment is done, considering
food and hydration intake. However, on
the first day of hospital admission, there
is a drawback due to a lack of systematic
dehydration assessment
• Assessing hydration status immediately
after admission is challenging, and there
is insufficient training to recognize clinical
dehydration in hospitals. While RMOs
have basic knowledge of dehydration
assessment, there is a need for prioritizing
clinical signs and symptoms
• Clinical assessment of dehydration is
essential, but RMOs often lack the patience,
training, and time for it
• Developing a check list and simple
educational content for RMOs on clinical
dehydration assessment in hospital settings
has been suggested as a valuable solution
FEE Deficits in Hospitalized Patients:
Intravenous or Oral Route
There are three indications for administering
IV fluids—resuscitation, replacement, and
maintenance. 55,56 Resuscitation fluids are
used to address a sudden loss of blood
volume or acute hypovolemia. Replacement
solutions are provided to correct deficits
that cannot be compensated by oral intake
alone. 55,56 Maintenance solutions are for
hemodynamically stable patients who cannot
or are not allowed to drink, ensuring they get
their daily water and electrolyte needs.55,56
Table 4: Criteria for patients or patient groups in whom FEE needs can be met orally (A), and criteria
for patients/patient groups in whom FEE needs should be supplemented through the IV route and
later shifted to the oral route (B)
(A) Criteria for patients or patient groups in whom FEE needs can be met orally
• Satisfactory recovery from illness
• No clinical signs of severe dehydration
• Absence of nausea, vomiting, and anorexia
• Fever, drowsiness, or nausea
• Patients on chemotherapy
• Patients on antibiotic therapy
• Patients with a positional drop in blood pressure causing giddiness or weakness
• Noncritically ill patients
• Conscious patients
(B) Criteria for patients/patient groups in whom FEE needs should be supplemented through
the IV route and later shifted to the oral route
• Patients with severe clinical dehydration
• Patients unable to consume orally
• Intubated patients
• Patients having swallowing issues
• Patients with increased fluid loss
• All patients in the ICU
• Patients with severe dehydration, concentrated urine, postural drop in blood pressure, early
sepsis, dengue-like syndromes, hyperglycemia, or severe viral fevers
• Sick, unconscious patients
FEE, fluid, electrolyte, and energy; ICU, intensive care unit; IV, intravenous
The experts have outlined the criteria for department and staff time for children
patients or patient groups for whom fluid and with moderate dehydration. 59 – 61 WHO-
electrolyte needs can be addressed through approved ORS with reduced osmolarity
oral means (Table 4A) and the criteria for proves effective in lowering diarrhea and
patients or patient groups in whom FEE needs vomiting episodes, hence reducing the need
should be supplemented through the IV route for IV rehydration in patients with acute
and later shifted to the oral route (Table 4B). illnesses.62–64 A randomized, double-blind,
The experts recommended that it is placebo-controlled trial showed that adding
important to assess the level of dehydration in Limosilactobacillus reuteri DSM 17938 and zinc
patients hospitalized for NDI and monitor the to ORS had similar effectiveness to regular ORS
need for rehydration along with energy needs without added probiotics and zinc in treating
during IV therapy, during de-escalation from acute diarrhea in well-nourished infants
IV to oral, and at discharge. The experts also and toddlers. The enriched ORS was well-
opined that if patients can tolerate enteral or tolerated with no adverse effects.65 According
oral feeds or have sufficient oral intake, it is to experts, probiotics speed up recovery.
advisable to contemplate shifting from IV to Probiotics with antibiotics speed the healing
oral hydration. process and help rebuild the gut microbiota.
Prebiotics also aid in the healing process.66
Addressing FEE Deficits in Table 5 shows key features of a product for
Hospitalized Patients nondiarrheal hospitalized individuals with FEE
Effectively managing FEE deficits is important deficiencies. Calcium, magnesium, and taurine
in acute illnesses. 36 The ORS, initiated in can assist muscle recovery; however, they have
1969, combines glucose and electrolytes in a limited capacity in the management of FEE
balanced manner and is globally endorsed by deficits in patients with chronic kidney disease
the United Nations Children’s Fund (UNICEF) (CKD) and metabolic illness.67–69
and the World Health Organization (WHO) The experts recommended oral rehydration
for clinical dehydration treatment.18,36,57 They therapy for FEE replenishment in (1) conscious
recommend a standardized formulation for and active patients, (2) patients capable of
ORS, applicable across all age-groups and swallowing properly, (3) depending on the
dehydration causes.18 Oral rehydration powders family’s capacity to record intake and follow
are cost-effective and have a longer shelf life directions, such as how much fluid to drink,
compared to ORS. Precise mixing is essential (4) patients with dehydration and electrolyte
for maintaining the right concentration. 58 imbalance, (5) during fluid loss, (6) during the
Studies show rare oral rehydration treatment recovery phase, (7) FEE to be started as soon
(ORT) failure, with potential benefits such as the patient is admitted (after assessment),
as reduced length of stay in the emergency and (8) while switching from IV to oral therapy.
Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024) 63
 Association of Physicians of India Expert Recommendations on Oral FEE
Disease conditions such as fever and
infections are hypermetabolic, and conditions
with nausea or vomiting can impair appetite,
resulting in insufficient fluid and energy
intake.36 Patients often refuse to eat more solid
food due to the satiety effect and anorexia/
weakness caused by acute illnesses.36 Malve
et al. highlighted that in NDIs, energy deficits can
be mitigated with calories from glucose in FEE
drinks.36 Additionally, it was also reported that
the ready-to-drink (RTD) format might also offer
the additional benefit of being more convenient
to consume and package in a sterile manner.36
Prescribing oral rehydration fluids with
precision and timeliness is crucial for effectively
combating dehydration, preferably at the
onset of illness.18 Recommending coconut
water for rehydration is not advisable based
on its glucose and electrolyte composition.70,71
Carbonated beverages and canned fruit juices
should be avoided and plain water may not be
ideal for replenishing electrolytes, particularly
for anorexic individuals who can only take
fluids.18 Table 6 lists suggestions on fluid
management for various conditions.
Oral fluid and electrolyte formulations
should have adequate energy content to meet
increased caloric, metabolic, and nutritional
demands in hospitalized patients with NDI. The
experts agreed that among oral fluids, RTD oral
fluids with known concentrations of electrolytes
and energy can have a superior impact on
recovery compared to homemade fluids.
Experts considered RTD electrolyte solutions
as good choices to avoid taste fatigue and
replenish FEE deficits in hospitalized patients,
including during IV to oral de-escalation and
at discharge. The expert panel recommended
RTD FEE formats to address FEE deficits in
hospitalized patients with medical illnesses
with calorie details or energy copackaged in
oral fluid and electrolyte formulations.
Feasibility of Ready-to-drink Tetra Packs
for NDI
Oral rehydration powder is cheaper, easier to
store, and lasts longer. To maintain glucose
and electrolyte levels, these products must
be mixed exactly as instructed. Incorrectly
measuring the dilution water volume might
affect electrolyte concentrations. Unpackaged
ORS chemicals increase the risk of errors. Thus,
premixed ORS is preferred over powdered
or handmade ones.58 The experts noted the
viability of RTD tetra packs. They stated that
tetra packs are clean, tasty, and can help
hospitalized patients meet nutritional needs
because of their nutrient and fluid information.
Hospitalized patients with inadequate
nutrition and dehydration may benefit from
RTD FEE tetra packs, which include a defined
concentration of electrolytes and energy.
64 Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024)
Table 5: Key attributes of a product to restore FEE deficits in patients hospitalized for NDI
Key attributes of a product to restore FEE deficits in patients hospitalized for NDI
• Noncaffeinated
• Nonalcoholic
• Noncarbonated
• Known concentration of electrolytes, energy content, and total osmolarity
• Only natural sugar content (no artificial sweeteners)
• Low in sugar content
• Hygienically prepared
• Specific concentrations of glucose, sodium, and other electrolytes optimize fluid absorption
through the gastrointestinal tract
• Palatable
• Combination of prebiotics and probiotics
• Added minerals such as calcium, magnesium, and taurine for faster muscle recovery
FEE, fluid, electrolyte, and energy, NDI, Nondiarrheal illness
Table 6: Fluid management for various health conditions
Conditions Fluids to avoid Recommended fluids
Cough, cold, fever, Caffeinated, carbonated Hygienic drinks
flu dehydrating drinks Homemade or RTD energy and electrolyte
drinks
Malaria, typhoid, Caffeinated, carbonated Homemade or RTD energy and electrolyte
chikungunya dehydrating drinks drinks
Heat-associated Dehydrating, carbonated Homemade or RTD energy and electrolyte drinks
diseases or caffeinated drinks Increased use of taurine, calcium, and
magnesium for muscle cramps
Nausea or vomiting Magnesium–potassium fluids
Energy drinks with electrolytes
Dengue Energy-restoring drinks with proper electrolyte
and energy balance
Mild hypoglycemia Sugary drinks such as fruit juice, soda, milk,
energy drinks with 12% sugar, or sweets with
above 10% sugar
Mild hypokalemia Fluids with potassium and magnesium
Mild hyponatremia Water with added salt or drinks with <12% sugar
72
Adapted from: Banerjee ; RTD, ready-to–drink
Hospitalized patients may find value in chronic obstructive pulmonary disease
RTD FEE tetra packs as healthcare providers (COPD), and pyrexia of unknown origin.
(HCPs) are aware of the contents, ensuring
transparency and informed choices. RTD FEE Challenges with Hydration in
is also effective in hospitalized patients due to Patients Hospitalized for NDIs
its known concentrations, palatability, clean Intravenous rehydration is a straightforward
packing, and child-friendliness. It belongs and effective method for directly supplying
in long-term hospitalizations throughout fluids to the intravascular fluid compartment.73
recuperation. IPD documentation must However, achieving the optimal fluid balance
include hydration recommendations. for patients may require a collaborative
The experts agreed that FEE management approach from an interprofessional team.73,74
is applicable and relevant as an adjuvant in The type, amount, and infusion rate of IV
hospitalized patients (various patient profiles) rehydration can vary based on factors such as
to facilitate the speed of recovery. Written body composition, dehydration level, cardiac
RTD FEE recommendations should be given output, and clinical parameters, such as urine
at the time of discharge of hospitalized output and blood pressure.73,74 Prescribing
patients to facilitate the speed of recovery. fluids can be challenging, especially for
RTD FEE formats with known concentrations patients with impaired homeostasis, like
of electrolytes and energy as adjuvants can those with renal or heart failure, or those
facilitate faster recovery in the elderly, patients experiencing excessive losses (due to
with diabetes, patients with inadequate food diarrhea). 73,75 Incorrect management of
intake and infectious NDI, and longstanding fluid assessment and monitoring can lead to
hospitalizations for cerebrovascular accidents, adverse outcomes, such as hyponatremia, fluid
 Association of Physicians of India Expert Recommendations on Oral FEE
overload, and hyperchloremic acidosis.73,76
Therefore, obstacles to IV therapy restrict
its application and promote the preference
for oral fluid alternatives. The experts
recommended administering oral fluids to
patients experiencing nausea, vomiting, and
anorexia, provided they can tolerate them to
address deficits. There are currently no strict
criteria or universally followed protocol for
assessing hydration in hospitalized patients.
The decision is typically made based on
the patient’s condition and urine output,
highlighting the need for a standardized
protocol. Besides, the transition from IV to
oral hydration is often delayed and requires
medical attention. Encouraging patients to
consume fluids orally is crucial, as there is a
lack of awareness among both patients and
doctors regarding the importance of oral
hydration. The experts expressed concerns
about the challenges involved in promoting
hydration among patients hospitalized for
NDIs (Table 7).
Improving Fluid Balance Monitoring
in Hospital Settings
Basis any sur vey, physicians generally
exhibit a moderate level of knowledge
about dehydration, indicating a potential
knowledge gap. Improving physicians’
knowledge about dehydration and fluid–
electroly te imbalance management in
NDIs could enhance real-world disease
outcom es . Higher k nowle dge scores
correlate with a proactive attitude and
p e rce i ve d b e t te r p at i e nt o u tco m e s .
Physicians with better knowledge scores
believe that recommending RTD f luid
and electrolyte replacement drinks can
shorten patient recovery time, potentially
reducing healthcare resource utilization.
Furthermore, lack of awareness, clinical
skills, and time constraints are identified
as factors contributing to the infrequent
identification of dehydration by physicians. D i s c lo s u r e s
It is important to note the significance of This study was sponsored by JNTL Consumer
Table 7: Challenges in encouraging hydration in honoraria from JNTL Consumer Health (India)
patients hospitalized for NDIs
• Lack of awareness about the importance of
hydration among HCPs
• Lack of compliance
• Ignorance of HCPs
• LOA
• Depression
• Cost of RTDs
• coronary syndrome: from molecular mechanisms
Difficulty in swallowing
• Heart failure
• Lack of awareness about the importance
of hydration among relatives of patients
HCP, healthcare provider; NDI, nondiarrheal illness; publication. They affirm that this report is
RTD, ready-to–drink
assessing dehydration levels in NDI patients
during hospitalization and monitoring
rehydration and energy needs during the
transition from IV to oral therapy. Initiatives
such as a comprehensive tool or checklist
and educational presentations on clinical
dehydration assessment for resident doctors
are recommended. Formal teaching sessions
for RMOs, distribution of pamphlets to HCPs,
and digital tools or reminders for hydration
assessment are suggested strategies.
Additionally, organizing train-the-trainer
programs for key hospital stakeholders
and conducting clinical outcome-based
studies on the importance of RTD fluid and
electrolyte replacement would be valuable.
C o n c lu s i o n
In summary, the burden of fluid and electrolyte
imbalance in hospitalized patients, particularly
those with NDI, poses significant challenges.
The prevalence of dehydration ranges from 30
to 70%, with diverse manifestations, such as
hypotonic, hypertonic, or isotonic conditions.
Assessment of hydration status at the time of
hospitalization is crucial for the well-being
of patients. Hence, collaborative efforts are
needed to create effective tools for assessing
hydration in hospitals, promoting a cultural
shift and a positive attitude toward proper
hydration among patients. However, there are
challenges in encouraging proper hydration,
which include a lack of awareness among
HCPs and patients, noncompliance, and
delayed transitions from IV to oral hydration.
To address these issues, improving physician
knowledge, enhancing awareness, and
implementing standardized protocols are
recommended, along with initiatives such
as educational tools and outcome-based
studies for effective fluid balance monitoring
in hospital settings.
Health (India) Pvt. Ltd. and all authors received
Pvt. Ltd. for participation in the Scientific
Advisory Board Meeting.
Funding
JNTL Consumer Health (India) Pvt. Ltd.
Author Contributions
All authors contributed to the development
and review of this Delphi consensus and
confirm that they have read the Journal’s
position on issues involved in ethical
consistent with those guidelines. All authors
Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024)
met the International Committee of Medical
Journal Editors (ICMJE) criteria, and those who
fulfilled those criteria were enlisted as authors.
All authors had access to the study data and
made the final decision regarding where to
publish these data. They approved submission
to this journal.
A c k n o w l e d g m e n ts
The authors especially acknowledge Dr Girish
Mathur and Dr Agam Vora for reviewing the
manuscript on behalf of the Association
of Physicians of India. The authors are also
grateful to BioQuest Solutions (a third-
party research agency) for conducting the
literature search and review, which was
funded by JNTL Consumer Health (India)
Pvt. Ltd.
Orcid
Jyotirmoy Pal https://orcid.org/0000-0001-
7769-9655
Sanjith Saseedharan https://orcid.org/0000-
0003-4299-4317
Prachee Sathe https://orcid.org/0000-0002-
1236-1669
Anuj Maheshwari https://orcid.org/0000-
0002-0924-7830
References
1. Lacey J, Corbett J, Forni L, et al. A multidisciplinary
consensus on dehydration: definitions, diagnostic
methods and clinical implications. Ann Med
2019;51(3-4):232–251.
2. Shaheen NA, Alqahtani AA, Assiri H, et al. Public
knowledge of dehydration and fluid intake practices:
variation by participants’ characteristics. BMC Public
Health 2018;18(1):1346.
3. Lee JW. Fluid and electroly te disturbances in
critically ill patients. Electroly te Blood Press
2010;8(2):72–81.
4. Dmitrieva NI, Burg MB. Increased insensible water loss
contributes to aging related dehydration. PLoS One
2011;6(5):e20691.
5. Bhatti A, Ash J, Gokani S, et al. Hydration stickers -
improving oral hydration in vulnerable patients. BMJ
Qual Improv Rep 2017;6(1):u211657.
6. Guyton AC, Hall JE. The body fluids compartments:
extracellular and intracellular fluids; interstitial fluids
and edema. In: Guyton AC, Hall JE (Eds). Textbook
of Medical Physiology. Philadelphia: WB Saunders
Company; 2000. pp. 263–379.
7. Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration,
and health. Nutr Rev 2010;68(8):439–458.
8. Liamis G, Liberopoulos E, Barkas F, et al. Diabetes
mellitus and electrolyte disorders. World J Clin Cases
2014;2(10):488–496.
9. Johnson EC, Bardis CN, Jansen LT, et al. Reduced water
intake deteriorates glucose regulation in patients with
type 2 diabetes. Nutr Res 2017;43:25–32.
10. Bellis A, Mauro C, Barbato E, et al. Stress-induced
hyperglycaemia in non-diabetic patients with acute
to new therapeutic perspectives. Int J Mol Sci
2021;22(2):775.
11. Dungan KM, Braithwaite SS, Preiser J-C. Stress
hyperglycaemia. Lancet 2009;373:1798–1807.
12. Harris E, Pérez L, Phares CR, et al. Fluid intake and
decreased risk for hospitalization for dengue fever,
Nicaragua. Emerg Infect Dis 2003;9(8):1003–1006.
65
 Association of Physicians of India Expert Recommendations on Oral FEE
13. Feliciano L, LeBlanc LA, Feeney BJ. Assessment
and management of barriers to fluid intake in
community dwelling older adults. J Behav Med
2010;1:3–14.
14. Miller HJ. Dehydration in the older adult. J Gerontol
Nurs 2015;41(9):8–13.
15. El-Sharkawy AM, Watson P, Neal KR, et al. Hydration
and outcome in older patients admitted to hospital
(The HOOP prospective cohort study). Age Ageing
2015;44(6):943–947.
16. Rowat A, Graham C, Dennis M. Dehydration in hospital-
admitted stroke patients: detection, frequency, and
association. Stroke 2012;43(3):857–859.
17. Edmonds CJ, Foglia E, Booth P, et al. Dehydration in
older people: a systematic review of the effects of
dehydration on health outcomes, healthcare costs
and cognitive performance. Arch Gerontol Geriatr
2021;95:104380.
18. Ghosh A, Bavdekar AR, Wadhwa N, et al. Role of oral
fluid, electrolytes and energy in various pediatric
illnesses beyond diarrhea: an Indian expert panel
consensus recommendation. Int J Contemp Pediatr
2023;10:429–438.
19. Blackmer A. PedSAP 2018 Book 2, Fluids and
Electrolytes. ACCP. 2018:7–25.
20. Mangus CW, Canares TL. Heat-related illness in
children in an era of extreme temperatures. PIR
2019;40:97–107.
21. Bernardo LM, Crane PA, Veenema TG. Treatment and
prevention of pediatric heat-related illnesses at mass
gatherings and special events. Dimens Crit Care Nurs
2006;25:165–171.
22. Nasa P, Jain R, Juneja D. Delphi methodology in
healthcare research: how to decide its appropriateness.
World J Methodol 2021;11(4):116–129.
23. Rüetschi U, Salazar CMO. Methodology of an e-Delphi
study to explore future trends in orthopedics
education and the role of technology in orthopedic
surgeon learning. JMSR 2022;6:121–137.
24. Rüetschi U, Olarte Salazar CM. An e-Delphi study
generates expert consensus on the trends in future
continuing medical education engagement by
resident, practicing, and expert surgeons. Med Teach
2020;42(4):444–450.
25. Burgess Kelleher A, Sweeney C, Foley T, et al. An
e-Delphi study to identify priority areas for education
on advance care planning in COPD management.
Respir Care 2020;65(3):347–354.
26. Galipeau J, Cobey KD, Barbour V, et al. An international
survey and modified Delphi process revealed
editors’ perceptions, training needs, and ratings of
competency-related statements for the development
of core competencies for scientific editors of
biomedical journals. F1000Res 2017;6:1634.
27. Shells R, Morrell-Scott N. Prevention of dehydration
in hospital patients. Br J Nurs 2018;27(10):565–569.
28. Reber E, Gomes F, Dähn IA, et al. Management
of dehydration in patients suffering swallowing
difficulties. J Clin Med 2019;8(11):1923.
29. Kear TM. Fluid and elec troly te management
across th e ag e co ntinuum . N ep hro l Nur s J
2017;44(6):491–496.
30. Lavizzo-Mourey RJ. Dehydration in the elderly: a short
review. J Natl Med Assoc 1987;79:1033–1038.
31. Hooper L, Bunn DK, Downing A, et al. Which frail older
people are dehydrated? The UK DRIE study. J Gerontol
A Biol Sci Med Sci 2016;71:1341–1347.
32. Phillips PA, Johnston CI, Gray L. Disturbed fluid and
electrolyte homoeostasis following dehydration in
elderly people. Age Ageing 1993;22:S26–S33.
33. Godfrey H, Cloete J, Dymond E, et al. An exploration
of the hydration care of older people: a qualitative
study. Int J Nurs Stud 2012;49(10):1200–1211.
34. Nagaraj S. Loss of appetite in adult patients:
effectiveness and safety of an appetite stimulating
66 Journal of the Association of Physicians of India, Volume 72 Issue 6 (June 2024)
medication in an open-label, investigator-initiated
study in India. J Nutr Metab 2022;2022:2661912.
35. Tiwaskar M. Perception, approach and management
of loss of appetite: a cross-sectional, questionnaire
based physician survey. J Assoc Physicians India
2020;68:55–60.
36. Malve H, Sathe P, Chakravarty P, et al. Knowledge,
attitudes, and practices regarding oral f luid,
electrolyte, and energy management in acute
nondiarrheal illnesses among physicians in India. J
Assoc Physicians India 2023;71(5):11–12.
37. Ibrahim SL, Alzubaidi ZF, Al-Maamory FAD. Electrolyte
disturbances in a sample of hospitalized patients from
Iraq. J Med Life 2022;15(9):1129–1135.
38. El-Sharkawy AM, Virdee A, Wahab A, et al. Dehydration
and clinical outcome in hospitalised older adults: a
cohort study. Eur Geriatr Med 2017;8(1):22–29.
39. Long CA, Marin P, Bayer AJ, et al. Hypernatraemia
in an adult in-patient population. Postgrad Med J
1991;67(789):643–645.
40. Guest JF, Panca M, Baeyens JP, et al. Health economic
impact of managing patients following a community-
based diagnosis of malnutrition in the UK. Clin Nutr
2011;30(4):422–429.
41. Shbeer A. Extensive lower limb deep vein thrombosis
provoked by gastroenteritis-induced dehydration: a
case report for unusual precipitating factor. Int Med
Case Rep J 2022;15:713–718.
42. Posthauer ME. Hydration: does it play a role in wound
healing? Adv Skin Wound Care 2006;19(2):74–76.
43. Xie Y, Bowe B, Li T, et al. Higher blood urea nitrogen
is associated with increased risk of incident diabetes
mellitus. Kidney Int 2018;93(3):741–752.
44. Comtois R, Bertrand S, Beauregard H, et al. Diagnostic
value of the determination of blood urea in dehydrated
patients with and without central diabetes insipidus.
Union Med Can 1990;119(6):317–321.
45. Lin WL, Chen YF, Wang J. Factors associated with
the development of delirium in elderly patients in
intensive care units. J Nurs Res 2015;23(4):322–329.
46. Roussel R, Fezeu L, Bouby N, et al. Low water intake
and risk for new-onset hyperglycemia. Diabetes Care
2011;34(12):2551–2554.
47. Hamrick I, Norton D, Birstler J, et al. Association
between dehydration and falls. Mayo Clin Proc Innov
Qual Outcomes 2020;4(3):259–265.
48. V in ce nt M , M ah e n dir an T. Imp rove m e nt of
f luid balance monitoring through education
a n d r at i o n a l i s at i o n . B M J Q u a l I m p r ov R e p
2015;4(1):u209885.w4087.
49. O usey K , Cut ting K F, Ro ger s A A , et al. T he
impor tance of hydration in wound healing:
reinvigorating the clinical perspective. J Wound
Care 2016;25(3):122–130.
50. B oy l e CN , Lo re n ze n SM , Co mpto n D, e t al .
Dehydration-anorexia derives from a reduction
in meal size, but not meal number. Physiol Behav
2012;105(2):305–314.
51. Saghaleini SH, Dehghan K , Shadvar K , et al.
Pressure ulcer and nutrition. Indian J Crit Care Med
2018;22(4):283–289.
52. Bak A, Tsiami A, Greene C. Methods of assessment
of hydration status and their usefulness in detecting
dehydration in the elderly. Curr Res Nutr Food Sci
2017;5(2):43–54.
53. Hooper L, Abdelhamid A, Attreed NJ, et al. Clinical
symptoms, signs and tests for identification of
impending and current water-loss dehydration
in older people. Cochrane Database Syst Rev
2015;2015(4):CD009647.
54. Jeyapala S, Gerth A, Patel A, et al. Improving fluid
balance monitoring on the wards. BMJ Qual Improv
Rep 2015;4(1):u209890.w4102.
55. Malbrain MLNG, Langer T, Annane D, et al. Intravenous
fluid therapy in the perioperative and critical care
setting: executive summary of the International Fluid
Academy (IFA). Ann Intensive Care 2020;10(1):64.
56. Van Regenmortel N, Jorens PG, Malbrain ML. Fluid
management before, during and after elective
surgery. Curr Opin Crit Care 2014;20:390.
57. Musekiwa A, Volmink J. Oral rehydration salt solution
for treating cholera: ≤ 270 mOsm/L solutions vs ≥
310 mOsm/L solutions. Cochrane Database Syst Rev
2011;2011(12):CD003754.
58. Leung A, Prince TCanadian Paediatric Society, Nutrition
and Gastroenterology Committee, . oral rehydration
therapy and early refeeding in the management of
childhood gastroenteritis. PCH 2006;11(8):527–531.
59. Atherly-John YC, Cunningham SJ, Crain EF. A
randomized trial of oral vs intravenous rehydration
in a pediatric emergency department. Arch Pediatr
Adolesc Med 2002;156(12):1240–1243.
60. Doan Q, Chan M, Leung V, et al. The impact of an
oral rehydration clinical pathway in a paediatric
emergency department. PCH 2010;15(8):503–507.
61. Bellemare S, Har tling L, Wiebe N, et al. Oral
rehydration versus intravenous therapy for treating
dehydration due to gastroenteritis in children: a
meta-analysis of randomised controlled trials. BMC
Med 2004;2:11.
62. Redkar M, Spegel C, Tesado C, et al. Wide variability
in osmolality of reconstituted powdered oral
rehydration salts due to disparity in the method of
preparation among Indian consumers. J App Pharm
Sci 2022;12(6):224–229.
63. Aghsaeifard Z, Heidari G, Alizadeh R. Understanding
the use of oral rehydration therapy: a narrative review
from clinical practice to main recommendations.
Health Sci Rep 2022;5(5):e827.
64. Barr W, Smith A. Acute diarrhea. Am Fam Physician
2014;89:180–189.
65. Maragkoudaki M, Chouliaras G, Moutafi A, et al.
Efficacy of an oral rehydration solution enriched
with lactobacillus reuteri DSM 17938 and zinc in
the management of acute diarrhoea in infants: a
randomized, double-blind, placebo-controlled trial.
Nutrients 2018;10(9):1189.
66. Roy S, Dhaneshwar S. Role of prebiotics, probiotics,
and synbiotics in management of inflammatory
bowel disease: current perspectives. World J
Gastroenterol 2023;29:2078–2100.
67. Moe SM. Rationale to reduce calcium intake in adult
patients with chronic kidney disease. Curr Opin
Nephrol Hypertens 2018;27(4):251–257.
68. Swaminathan R. Magnesium metabolism and its
disorders. Clin Biochem Rev 2003;24(2):47–66.
69. Chesney RW, Han X, Patters AB. Taurine and the renal
system. J Biomed Sci 2010;17:S4.
70. Adegoke A, Bamigbowu OE, George-Opuda I, et al.
Electrolyte and glucose contents of ripe and unripe
coconut liquid as source of oral rehydration solution.
Int J Appl Res 2012;5(1):18–21.
71. Burns DT, Johnston EL, Walker MJ. Authenticity and
the potability of coconut water - a critical review. J
AOAC Int 2020;103(3):800–806.
72. Banerjee P. Restoration Guidelines. 2018. Epub ahead
of print 22 March 2018.
73. Gawronska J, Koyanagi A, López Sánchez GF, et al.
The prevalence and indications of intravenous
rehydration therapy in hospital settings: a systematic
review. Epidemiologia (Basel) 2022;4(1):18–32.
74. Wo o d C . Fluid management: an up date for
perioperative practitioners. JPP 2021;31:71–79.
75. Frost P. Intravenous fluid therapy in adult inpatients.
BMJ 2015;350:g7620.
76. Brossier DW, Tume LN, Briant AR, et al. ESPNIC clinical
practice guidelines: intravenous maintenance
fluid therapy in acute and critically ill children—a
systematic review and meta-analysis. Intensive Care
Med 2022;48:1691–1708.