PRE-ABSORPTIVE SATIETY: RELEVANCE OF ANTICIPATORY MECHANISMS CARE FOR PATIENTS WITH THIRSTABSTRACT
Objective: to understand the physiological aspects involved in pre-absorptive thirst satiety based on advances in neurophysiology and their applicability to healthcare.
Method: this is a reflective study that compiles physiological phenomena related to the form of satiety, describing the neurophysiological pathway for pre-absorptive thirst satiety.
Results: the anticipatory mechanisms involved in thirst inhibition are related to thermoreceptors, osmoreceptors, mechanoreceptors, gastric and cognitive mechanisms. The use of cold temperature is key to pre-absorptive satiety, as its stimuli are transmitted to the cortical and limbic regions, providing a sensation of pleasantness, gratification and pleasure. In this way, individuals reach pre-absorptive thirst satiety in a few minutes.
Conclusion: liquid or solid contents at a cold temperature help to achieve pre-absorptive thirst satiety, as they activate mechanisms that anticipate intake inhibition. This innovative path should be used intentionally for patients who experience prolonged water restriction, as they do not depend on the absorption of liquids by the gastrointestinal tract.
DESCRIPTORS:
Thirst; Arginine vasopressin; Satiety response; Osmolar concentration; Nursing care
RESUMO
Objetivo: Compreender os aspectos fisiológicos envolvidos na saciedade pré-absortiva da sede baseados em avanços na neurofisiologia e sua aplicabilidade para a assistência de saúde.
Método: estudo reflexivo, que compila os fenômenos fisiológicos relacionados a forma de saciar, descrevendo o caminho neurofisiológico para a Saciedade Pré-absortiva da sede
Resultados: Os mecanismos antecipatórios envolvidos para inibição da sede relacionam-se com termorreceptores, osmorreceptores, mecanorreceptores, mecanismos gástricos e cognitivos. A utilização da temperatura fria é a chave para a saciedade pré-absortiva, pois seus estímulos são transmitidos às regiões corticais e límbicas conferindo sensação de agradabilidade, gratificação e prazer. Dessa forma, o indivíduo alcança a saciedade pré-absortiva da sede em poucos minutos.
Conclusão: Conteúdos líquidos ou sólidos em temperatura fria auxiliam no alcance da saciedade pré-absortiva da sede, pois ativam mecanismos que antecipam a inibição da ingestão. Este caminho inovador deve ser utilizado com intencionalidade para pacientes que experienciam a restrição hídrica por tempo prolongado, pois independem da absorção de líquidos pelo trato gastrintestinal.
DESCRITORES:
Sede; Arginina vasopressina; Resposta de Saciedade; Concentração osmolar; Cuidados de Enfermagem
RESUMEN
Objetivo: comprender los aspectos fisiológicos involucrados en la saciedad de la sed preabsortiva a partir de los avances en neurofisiología y su aplicabilidad al cuidado de la salud.
Método: estudio reflexivo, que recopila los fenómenos fisiológicos relacionados con la forma de saciar la sed, describiendo el camino neurofisiológico hacia la saciedad preabsortiva de la sed.
Resultados: los mecanismos anticipatorios implicados en la inhibición de la sed están relacionados con termorreceptores, osmorreceptores, mecanorreceptores, mecanismos gástricos y cognitivos. El uso de la temperatura fría es la clave para la saciedad preabsortiva, ya que sus estímulos se transmiten a las regiones corticales y límbicas, confiriendo una sensación de agrado, gratificación y placer. De esta manera, el individuo consigue saciar la sed mediante preabsorción en unos pocos minutos.
Conclusión: los contenidos líquidos o sólidos a temperaturas frías ayudan a conseguir la saciedad preabsortiva de la sed, ya que activan mecanismos que anticipan la inhibición de la ingesta. Esta vía innovadora debe utilizarse intencionalmente en pacientes que experimentan restricción de agua durante un período prolongado, ya que son independientes de la absorción de líquidos a través del tracto gastrointestinal.
DESCRIPTORES:
Sed; Arginina vasopresina; Respuesta de saciedad; Concentración osmolar; Atención de enfermería
INTRODUCTION
When an individual is under water restriction, a complex neurohormonal and behavioral regulation mechanism begins, triggered by osmotic and volume changes, which generate an imperative search for water1. If not quenched, thirst has the potential to generate intense discomfort accompanied by attributes such as dry mouth, dry lips, changes in tongue and saliva texture, dry throat, bad taste in the mouth and the desire to drink water2. Although it triggers feelings of weakness and even suffocation in patients with water restriction3,4, thirst is rarely identified, measured and treated by healthcare teams5.
One challenge observed in clinical practice involves identifying patients at risk of developing thirst. For this to occur, healthcare professionals must be able to intentionally look at groups that have restricted fluid intake, such as surgical patients6 and chronic kidney patients. Another important and overlooked risk factor is invasive procedures, such as orotracheal intubation performed on surgical and critically ill patients, which result in mucosa dryness due to keeping the oral cavity open for a long period7.
Prolonged fasting, guided by health teams, exceeds the scientific recommendations of multimodal protocols that advise a two-hour restriction on clear liquids, reaching exorbitant levels of 216 hours without ingesting solids or liquids6. This a worrying scenario, corresponding to a reality where around 30% to 40% of patients receive empirical care8. These data support the fact that professionals promote the already deep-rooted culture that “thirst is a price to be paid when one wants to perform an anesthetic-surgical procedure safely” 5.
Given this problem, how can a patient with fasting prescription be satiated? What are the physiological aspects involved in pre-absorptive thirst satiation based on advances in neurophysiology and their applicability to healthcare?
Two mechanisms can be activated to achieve satiety. Post-absorptive mechanisms, when the gastrointestinal tract (GIT) needs to absorb the ingested liquid to correct plasma osmolarity, and pre-absorptive mechanisms, in which an anticipatory system is activated in specific brain regions and promotes satiety quickly, before liquid absorption occurs in the GIT9-11.
Satiating without absorbing large volumes through the GIT is the key point of safe treatment of thirst for patients prescribed pre- and post-operative fasting, for instance.
Considering the relevance of pre-absorptive mechanisms for safe healthcare practice and the innovative approach to assisting patients who suffer unnecessarily from a symptom that is systematically undervalued in healthcare institutions, it is justified to carry out a synthesis of evidence gathered for thirst management that supports the action of effective strategies to achieve pre-absorptive satiety. To this end, this theoretical study aimed to understand the physiological aspects involved in pre-absorptive thirst satiety based on advances in neurophysiology and their applicability to healthcare.
METHOD
This is a reflective study with analysis carried out in light of the principles of biological sciences, with specific concepts in neurophysiology that can justify in depth clinical practice in nursing during thirst management.
The studies that supported this work were selected from articles and book chapters, stored on a drive, totaling 700 articles specific to the symptoms of thirst and satiety, which were gathered by the research group over 10 years of research into perioperative thirst.
After countless readings, there was a need to compile in a single study physiological phenomena related to the form of satiety, describing a neurophysiological pathway for pre-absorptive satiety of thirst of a patient who receives a strategy to relieve thirst.
GENESIS OF THIRST
An individual’s ability to perceive the internal condition of their organism and generate behaviors is called interoception. This process is capable of regulating the behavior of hunger, thirst, fullness/satiety, pain and temperature12.
The presence of certain stimuli is necessary for humans to exhibit water-seeking behavior. Visceral stimuli, related to dry mouth and viscous saliva, and motivational stimuli trigger the need for water intake12. The sensation of thirst, although apparently simple, involves a complex network of neural pathways integrated with each other, whose purpose is to detect physiological changes in the organism and generate behavioral responses to the search for water11.
To understand these neural pathways, mapping of the main brain regions involved in the genesis, regulation and satiety of thirst was carried out, such as anterior and posterior cingulate cortex, orbitofrontal cortex13-14, thalamus, lamina terminalis and hypothalamus15.
To better understand this mechanism, we will describe below two fundamental areas for the body’s water control. The first comprises the hypothalamus, which is a small structure but has great regulatory potential, as it has two nuclei that coordinate the production of arginine vasopressin (AVP), the supraoptic nucleus (SON) and the paraventricular nucleus (PVN). The second, the lamina terminalis, is able to control the onset of thirst through the three structures that comprise it, called organum vasculosum of the lamina terminalis (OVLT), median preoptic nucleus (MnPO) and subfornical organ (SFO). They detect osmotic changes in the body in real time to induce thirst as well as send messages to the hypothalamus for AVP production16.
AVP, known as antidiuretic hormone, is synthesized mainly by the SON and stored in the posterior pituitary gland. When secreted into the bloodstream, it acts on aquaporin 2 receptors, increasing water permeability in the renal collecting ducts, conserving it in an attempt to maintain the balance between solute and solvent. This mechanism is traditionally known, and recent studies also reveal AVP secretion and/or inhibition by non-osmotic means16-18.
Non-osmotic stimuli, such as the presence of dry mouth, dry pharynx14, subjective and cultural characteristics such as the thought of drinking water18, fluid temperature and palatability, are factors that also influence the presence or satiety of thirst12. Therefore, they are relevant components to be considered when caring for thirsty patients.
Recent studies reveal that the process of gratification due to the presence of water in the mouth can deactivate areas such as the lamina terminalis and hypothalamus and that, therefore, such stimuli could temporarily inhibit AVP secretion and the sensation of thirst10,15,19.
It is important to note that the mechanisms of AVP secretion and the sensation of thirst complement each other in parallel. While AVP prevents water deficit through renal water permeability, thirst triggers the search for volume gain/replacement. During the pre-absorptive satiety process, the AVP secretion mechanism must be preserved in order to avoid dehydration.
Understanding the physiological mechanisms that can stimulate or inhibit thirst and AVP secretion, without using osmotic/volemic stimuli, has allowed a new perspective and new possibilities for the individual’s search for satiety, even if temporarily16,19.
PRE-ABSORPTIVE SATIETY
There are two ways for an individual to achieve satiety. The first and best known is called post-absorptive satiety and occurs between 12 and 25 minutes after water intake. In this process, oral ingestion and liquid absorption by the GIT are necessary. Satiety and inhibition of fluid consumption occur when the initial osmolarity deficits begin to be corrected9,20.
The second method, pre-absorptive satiety, is still little explored in clinical practice and occurs approximately 2 minutes after liquid ingestion. This mechanism involves primarily oral stimuli in thermoreceptor regions called Transient Receptor Potential Melastatin (TRPM8)20, osmoreceptors and mechanoreceptors. Subsequently, we will explore the mechanisms involved in this satiety.
TRPM8 is present in several regions of the body and has been the subject of study in different areas of science. When located in the trigeminal and glossopharyngeal nerves22, it has clinical relevance for thirst quenching, as it receives peripheral stimuli of cold temperature and menthol substances in the oral mucosa and sends information to the limbic cortical areas, promoting a sensation of freshness and pleasantness, helping to relieve the symptoms of dry mouth and thirst20.
Pre-absorptive satiety also occurs due to the presence of oral osmoreceptors and mechanoreceptors. Osmoreceptors detect the composition of fluids in the oral cavity and how hydrated the mucosa is, whereas mechanoreceptors detect the mucosa dryness by the sliding of one mucosa over the other during swallowing or tongue movement20-21.
The anticipatory mechanism involving thermoreceptors in the oral cavity is related to the gratification process caused by sensory and gustatory perception, evoked by cold and menthol. The stimuli initiated in the trigeminal and glossopharyngeal nerves in the oral cavity are transmitted to regions of SFO, OVLT and MnPO21, the latter retransmitting information to the hypothalamic, thalamus, cingulate cortex and orbitofrontal cortex areas, promoting the sensation of pleasantness, gratification and pleasure, achieving pre-absorptive satiety of thirst10,23.
Another anticipatory mechanism is swallowing. In this process, during swallowing, inhibitory stimuli are sent to the main brain areas of thirst, such as the anterior, posterior and orbitofrontal cingulate cortex14. These inhibitory stimuli occur through the glossopharyngeal nerve, which, in addition to innervating 1/3 of the tongue, conducts information originating in the pharyngeal-esophageal region, through the swallowing mechanism16, with the purpose of avoiding excess fluid intake24.
Gastrointestinal factors are also related to pre-absorptive satiety. In this process, liquid intake is inhibited due to gastric distension caused by the presence of a variety of substances, whether liquid, solid or even gaseous, in the stomach9,16. Gastric distension decreases the electrical activity of SON and PVN of the hypothalamus.
Finally, cognitive factors participate in pre-absorptive satiety by involving a variety of psychological aspects that influence liquid intake or inhibition. Cultural aspects such as daily intake habits or the palatability of tastes and textures are related9,16. It is understood that each characteristic of the food or liquid can generate inhibition of ingestion, due to the reduction of sensory sensations25. Fluid taste and texture can cause aversion and lead to inhibition of early intake9.
The main mechanisms involved in pre-absorptive thirst satiety are summarized and illustrated in Figure 1.
Schematic illustration for achieving pre-absorptive thirst satiety. Londrina, PR, Brazil, 2021.
APPLICABILITY FOR THE CARE OF PATIENTS WITH THIRST
Considering the importance of the thirst symptom and the entire neuroendocrine complex evoked by this symptom, it is necessary for health teams to explore ways to alleviate this discomfort, based on the mechanisms involved in pre-absorptive satiety. What is observed in clinical practice, however, is continuity of empirical and inefficient actions for achieving satiety in thirsty patients, such as moistening the cavity with gauze and saline solution and/or distilled water at room temperature.
Fasting is a daily routine for some patients. Chronic kidney disease patients undergoing renal replacement therapy, for instance, are subjected to daily fluid restriction in order to prevent cardiac overload, acute pulmonary edema, hypertension and congestive heart failure. Approximately 75.9% of chronic kidney disease patients report significant discomfort from fluid restriction26, demonstrating that the need for water is a primitive biological behavior that reflects the body’s state of alert.
Critically ill patients also present thirst, and its etiology is related to large fluctuations in plasma osmolarity, since they present dysfunctions that lead to hydroelectrolytic imbalances, such as hypernatremia. The high concentration of solutes in the plasma leads to dehydration and, consequently, visceral characteristics, such as oral cavity dryness. Dry mouth is the attribute most related to the presence of thirst2, and is observed in this group of patients. Furthermore, it occurs in the presence of orotracheal intubation, hypoxia, stomatitis and other systemic disorders, such as Sjogren’s syndrome, which affects salivary production7.
In surgical patients, feeling thirsty is related to perioperative fasting, anxiety, medications used during the anesthetic procedure, and loss of blood volume during surgery. Thirst is considered a stressor and results in worsening anxiety, dehydration, oirritability, despair, and suffering2,5.
The etiological factors and repercussions of water deficit in the body are diverse. They can present themselves as fatigue, headache, irritation, stress, anxiety, dry mouth, dry lips, thick tongue and saliva, bad taste in the mouth and desire to drink water5. These attributes were recently published in a nursing diagnosis proposal to the North American Nursing Diagnosis Association (NANDA) 27.
Faced with this problem, simple, effective and innovative strategies were developed to effectively alleviate the thirst of surgical patients.
A menthol chewing gum was tested three hours before a surgical procedure for thirst relief. The purpose of this chewing gum was to reduce thirst by increasing salivary production through mechanical and chemical stimulation of the salivary glands, hydrating the oral mucosa, increasing swallowing, in addition to containing menthol flavoring, which acts on receptors located in the oropharynx (TRPM8). The study demonstrated the effectiveness of menthol chewing gum in significantly reducing the intensity and discomfort of thirst (high level of evidence) 25.
A 30 ml mentholated popsicle was also offered to a patient three hours before a surgical anesthetic procedure. The intervention proved to be significantly effective in relieving the intensity and discomfort of thirst, due to the action of the low temperature and menthol with action on TRPM8 (high level of evidence) 27.
Another ice pop with only 10 ml versus water at room temperature in the same volume was also offered in the postoperative period, still in the anesthesia recovery room. The study findings demonstrate the effectiveness of the cold strategy when compared to room temperature, due to the action of pre-absorptive satiety mechanisms (high level of evidence) 28.
Another randomized clinical trial conducted in the immediate postoperative period (IPO) compared a mentholated popsicle associated with mentholated lip balm with an ice popsicle and a lip balm without menthol. The study aimed to reduce the intensity and discomfort caused by thirst. This study did not show any significant difference between the interventions. In both groups, there was a significant reduction in the outcomes studied, thus considering that both strategies act on pre-absorptive satiety due to the use of low temperatures and menthol (high level of evidence) 29.
A quasi-experimental study assessed the physiological hormonal profile of AVP concentrations in volunteers with water deprivation who received a 20 ml ice popsicle every 15 minutes for 45 minutes. A reduction in thirst intensity and discomfort was observed, associated with a physiological reduction in AVP immediately after the first ice popsicle, and this reduction continued after receiving the second ice popsicle (moderate level of evidence) 19.
What makes these strategies simple and yet effective? The answer lies in the use of cold temperatures, whether or not associated with menthol, which are capable of acting on the anticipatory mechanisms of satiety. These strategies promote increased salivation, activation of TRPM8, and swallowing mechanisms, generating allesthesia and reducing the sensation of thirst.
Furthermore, both ice popsicles and mentholated popsicles, as well as mentholated chewing gum and mentholated lip balm, are possible strategies to be produced, stored and handled, making them applicable in clinical practice.
Thus, understanding this neuroanatomical and hormonal complex allows healthcare teams to move away from empiricism and implement evidence-based clinical practice. Teams must use effective and safe interventions to achieve pre-absorptive thirst satiety, thereby relieving the intensity and discomfort of thirst experienced by patients who are submitted to daily water restriction30.
CONCLUSION
The genesis of thirst is a complex neural pathway that integrates anatomical, physiological, visceral and motivational functions. The main areas involved in this process are the cingulate cortex, orbitofrontal cortex, hypothalamus and terminal lamina. Pre-absorptive thirst satiety acts in these areas through oropharyngeal receptors, such as TRPM8, present in the nerve endings of the trigeminal and glossopharyngeal nerves, when using a cold or mentholated strategy.
Patients subjected to water restriction belong to the risk group for developing thirst, due to changes in osmolarity and the presence of peripheral signs such as dry mouth.
The clinical importance of this study was to compile scientific knowledge about pre-absorptive thirst satiety, in addition to presenting strategies that act on this type of satiety, such as ice popsicles, mentholated popsicles, mentholated gum and mentholated lip moisturizer, enabling their use in clinical practice, aiming to alleviate this intense and distressing symptom that is thirst.
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NOTES
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ORIGIN OF THE ARTICLE
Excerpt from the thesis “Efeitos do picolé mentolado sobre a sede e secreção de vasopressina: ensaio clínico randomizado”, presented to the Doctoral graduate Program, Universidade Estadual de Londrina, in 2023.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research Universidade Estadual de Londrina Research Ethics Committee, under Opinion 4.305.482 and Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação Ética) n.º 33419120.9.0000.523.
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TRANSLATED BY
Letícia Belasco.
