Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Comment on 10% Dextrose vs 50% Dextrose

In response to Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial. There is this comment from Can’t say, clowns will eat me –

Ok, I’ve seen this study many times and even referenced it to many people at differing levels of providership. That being said one of the most interesting arguments I’ve heard is that basically the people saying this thought, their blood sugar is critically low and they’re killing brain cells and if we don’t push D50 and push it as fast as possible we’re going to essentially cause a brain injury.

There is no reason to believe that there is any harm to the patient with 10% dextrose.

That brain damage assumes that it takes longer for the patient to be treated with 10% dextrose than with 50% dextrose.

The average time to return to full consciousness with 50% dextrose?
 
 

8 minutes.

 
 
The average time to return to full consciousness with 10% dextrose?
 
 

8 minutes.

 
 
Where is the difference?

Maybe the people making these excuses are the ones with brain damage causing them to see a big difference between 8 minutes and 8 minutes, but those of us without brain damage realize that time does not speed up or slow down depending on the concentration of dextrose.

The brain damage is more likely just operator error. The operator error is bias. The people are biased against something they are not familiar with. This leads them to assume that there are problems with the unfamiliar, even though these problems do not exist.

Also, I’ve heard the argument as to the previous post about the administration guidelines of the approximately 30 minutes it’d take to push it being too long

There is no 30 minutes.

30 minutes is a lie from the biased opponents of better patient care.

. . . as above but also that tied in with the D10 drip to stop rebound hypoglycemia just not being “practical” because we can’t spend that long with the patient, etc. Why is that wrong? Is it better to cause tissue necrosis? rebound hypoglycemia and by their own logic, even further brain damage?

There were differences in scene times between the 10% dextrose and the 50% dextrose groups, but that is to be expected with any new and unfamiliar method of treatment. In this study, a 3 way stopcock was used to draw 10% dextrose from the IV bag into a syringe, then switch the direction of flow to the patient and push the 10% dextrose that had been drawn into the syringe. This is more complicated than the method of giving 50% dextrose, but there are many other ways to give 10% dextrose.

The difference in time was only in the total scene time, not in the treatment time.
 
 

The fastest scene times and the fastest recovery times were in the 10% dextrose group.

 
 
This raises questions about the skills of the people who claim that we cannot give an adequate amount of 10% dextrose in less than 30 minutes –

How drunk and stupid are they?

But they aren’t necessarily drunk, or even stupid. What they are is biased.

Biased people aren’t necessarily bad people, but they are dangerous.

What else do we call refusing to provide better care to our patients just because of bias?

A refusal to provide better care is a demand to provide worse care. This is dangerous.

If this were a National Registry of EMTs testing station, nobody would have any problem with whatever 10% dextrose administration method was being tested, because we would practice until they were able to do it consistently and quickly.

If we cannot consistently wake up hypoglycemic patients with 10% dextrose in the same amount of time as with 50% dextrose, maybe we should not be allowed to use dopamine or lidocaine or amiodarone drips.

Clearly a drip set is more than a little bit beyond our capabilities as paramedics.

And if we can’t manage a simple IV drip set, we certainly can’t manage an endotracheal tube. 😳

Perhaps we do not want to use that argument.

Why not just come in and establish a line and administer D10 via a drip. And, the administrators will love this. You won’t be tied up on scene unavailable, you won’t be unavailable going to the hospital after the call without a patient(in which case you oftentimes will be paid little or nothing) and you’ll transport more and make more money for the company. For those in the private sector, wouldn’t that be a boon to reimbursements?

I don’t see any need to change transport for a difference in recovery time that is zero minutes.

There is no important difference in treatment time.

There is a dramatic difference in the potential for bad outcome with the unnecessary high concentration of the 50% dextrose.

Does a surgeon require the greater risk of general anesthesia for something that can be treated under local anesthesia?

Do we fly every patient?

Do we drive everywhere with lights and sirens?

We consider the benefits and risks of treatments.

We use the treatment that provides adequate benefit without unnecessary risk.

50% dextrose provides a greater risk for no greater benefit.

The picture is one I found labeled as being from Annals of Emergency Medicine of 50% Dextrose extravasation, but I do not know anything about which issue it is from or any other details – update – the image credit is below.

Images in emergency medicine. Dextrose extravasation causing skin necrosis.
Levy SB, Rosh AJ.
Ann Emerg Med. 2006 Sep;48(3):236, 239. Epub 2006 Feb 17. No abstract available.
PMID: 16934641 [PubMed – indexed for MEDLINE]

.

Comments

  1. In London we only have the option of using 10%, which has always in my experience proved adequate and fast working. The maximum dose is 300mls IV. I don’t think I’ve ever come close to giving the full amount! The only difference is that our “protocols” insist on a large bore cannula…

    • insomniacmedic,

      In London we only have the option of using 10%, which has always in my experience proved adequate and fast working.

      In the US, we are regularly told that speed of administration of 50% dextrose is important. The speakers tell us that 50% dextrose works blindingly fast, while 10% dextrose is slower than the brain death that can only begin after EMS arrives and begins treatment.

      We continue to listen to the wrong people.

      The maximum dose is 300mls IV. I don’t think I’ve ever come close to giving the full amount!

      300 ml of 10% dextrose is 30 gm, or one amp of 50% dextrose and 1/5 of another amp.

      The only difference is that our “protocols” insist on a large bore cannula…

      At least with 10% dextrose, the complications from extravasation would be much less harmful.

      The complications are due to the osmolarity and quantity of the fluid that leaks into the tissues.

      10% dextrose has an osmolarity of 505 mOsmol/L.

      50% dextrose has an osmolarity of 2520 mOsmol/L.

      http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?id=4785

      Some substances have the potential to cause tissue damage by having an osmolality greater than that of serum (281-289 mOsmol/L) 63

      Hyperosmolar substances such as hypertonic glucose solutions or X-ray contrast media draw fluid from cells resulting in cell death by dehydration

      http://www.extravasation.org.uk/druginfusate.htm

      Unless my understanding of osmolality and osmolarity is wrong, they are not very different.

      10% dextrose is slightly less than twice the osmolarity of serum.

      50% dextrose is almost 9 times the osmolarity of serum.

      10% dextrose is about 220 mOsmol/L higher than serum.

      50% dextrose is about 2,235 mOsmol/L higher than serum.

      If the dose makes the poison, extravasated 50% dextrose can be very poisonous.

      .

  2. When we had to use 500mL bags of D5W when we ran short of D50 you would have thought the world was coming to an end the way some people acted towards it. I found it better for the patient and more fun to do by comparison.

    From an administrative standpoint, you can buy a case of 25 of the D5W bags for the price of 9 of the prefilled 50mL D50 syringes. Save money AND deliver better care, a winning combination these days.

    • Russell,

      When we had to use 500mL bags of D5W when we ran short of D50 you would have thought the world was coming to an end the way some people acted towards it. I found it better for the patient and more fun to do by comparison.

      It is amazing how easy it can be if we look at the results, rather than base our decisions on tradition.

      From an administrative standpoint, you can buy a case of 25 of the D5W bags for the price of 9 of the prefilled 50mL D50 syringes. Save money AND deliver better care, a winning combination these days.

      But it requires change.

      .

  3. Um….if someone did this to me and that happened to my arm….there would be hell to pay. I have hypoglycemia, but you ain’t touchin me with a needle unless I’m REALLY OUT! I am in medic school and do realize the importance….but don’t touch me with one! That’s all I say. That picture….wow. ew.

    • Halley,

      Um….if someone did this to me and that happened to my arm….there would be hell to pay. I have hypoglycemia, but you ain’t touchin me with a needle unless I’m REALLY OUT! I am in medic school and do realize the importance….but don’t touch me with one! That’s all I say. That picture….wow. ew.

      First, the dextrose needs to leak into the surrounding tissue. We do not know how common extravasation is. I have seen citations of numbers that are all over the place. We do not have good follow up of EMS errors.

      You probably wear some sort of Medical Alert identification. You could look into getting one that says only use 10% dextrose.

      Most extravasation injuries develop pain in the hours after injection and should be treated as quickly as possible. If not treated, the injury can be expected to continue to get worse over the following months.

      .

  4. I appreciate the immaturity and name calling in the article. How about presenting the facts without calling other medics stupid or dangerous. We have enough lawyers looking for ways to sue us, we need to stand as one not point fingers. If you have a better treatment, present it with bare facts. I have no problem with this particular treatment, just the author.
    Also, in 10 years I’ve never seen a medic screw up with D50 as described.

    • Will,

      I appreciate the immaturity and name calling in the article.

      Another satisfied customer.

      How about presenting the facts without calling other medics stupid or dangerous.

      Because I can do both. 🙂

      We have enough lawyers looking for ways to sue us, we need to stand as one not point fingers.

      No. We need to improve our patient care, not circle the wagons and protect our stupid and our dangerous.

      If you have a better treatment, present it with bare facts.

      I have presented what should be enough evidence.

      I will continue to present more.

      Why do you defend a treatment in spite of the information I have already provided?

      I have no problem with this particular treatment, just the author.

      Good. Then I should expect you to encourage your medical director to change your protocols.

      Also, in 10 years I’ve never seen a medic screw up with D50 as described.

      What do you base that statement on?

      What method do you use to document that there was no extravasation, when you leave the patient at home or at the hospital?

      How long do you follow up on the outcome of patients after an extravasation?

      The initial damage is just discomfort to the affected area, but the damage can continue for months. Things can progress to the point that is shown in the picture, but the injury can be worse.

      Is it worth it to continue to do things the way we have always done things?

      Is it better to use the kind of wording to get the attention of people who are interested in good patient care, but are not aware of the problem?

      I point out the problems, not to get the attention of lawyers, but to get the attention of those who do not want to harm patients.

      This is a change that is long overdue.

      Maybe I need to offend some easily offended people, who have distorted priorities, in order to get people to improve patient care. I am OK with that.

      .

    • I appreciate the attitude in this article as it reflects my own exasperation with STUPID EMS “professionals” bringing the rest of us down. I agree we need to stand as one and I am willing to do so. But I would like to get rid of the incompetent ones among us in the process…. I dont like being associated with them as I lose some intelligence by association.

      • Lungs,

        I appreciate the attitude in this article as it reflects my own exasperation with STUPID EMS “professionals” bringing the rest of us down.

        Thank you.

        I agree we need to stand as one and I am willing to do so. But I would like to get rid of the incompetent ones among us in the process….

        We can stand as one, but there appear to those who want us to stand as one against doing what is best for our patients, because that would mean admitting that what we have been doing has been harmful.

        We can stop causing harm or we can attack anyone who points out the harm.

        I agree that we need to stand as one for improved patient care.

        I dont like being associated with them as I lose some intelligence by association.

        You don’t lose any intelligence, but you may be seen as losing some intelligence by association.

        .

  5. First, all of the name calling takes away any credibility you may have had. I have been in EMS for 30 years and have never had /nor reviewed and case that had any problems with D50. One just needs to be sure that you have a patent IV. We give lower concentrations in peds and the elderly.

    • Dave,

      First, all of the name calling takes away any credibility you may have had.

      It’s OK. You don’t have to worry about my credibility. I provide links to valid research. Your opinion of my credibility is just not relevant.

      I have been in EMS for 30 years and have never had /nor reviewed and case that had any problems with D50.

      What do you base that statement on?

      What method do you use to document that there was no extravasation, when you leave the patient at home or at the hospital?

      How long do you follow up on the outcome of patients after an extravasation?

      The initial damage is just discomfort to the affected area, but the damage can continue for months. Things can progress to the point that is shown in the picture, but the injury can be worse.

      One just needs to be sure that you have a patent IV.

      If we could always be sure that we have a patent IV, we would never have any problems with extravasation.

      People claim that they do not have any problems with intubation, but when their system is studied, the results show that they have huge problems.

      If we do not assess for something, how do we know there is no problem with the way we do it?

      We give lower concentrations in peds and the elderly.

      The lower doses for pediatric and geriatric patients is due to the fluid shifts that can occur when pushing high osmolarity fluids and causing significant fluid shifts.

      However, with both pediatric and geriatric patients, the complications of extravasation are much more significant. The pediatric 25% dextrose is also an unnecessarily high concentration of dextrose.

  6. For what it’s worth, there was an old grouchy ER doc way back when I was getting started that used to routinely chew out medics for using D50. This was back in the stone ages and you had to call for orders on everything. He would routinely deny the D50 request and tell them to start a line of D5W. This would be followed by the fore mentioned buttchewing upon arrival at the ER.

    The whole point of this is that I was using D5W on these patients 20 years ago. They came to in roughly the same time, and it was a much more gentle process. The only reason people use D50 is because they want to get a refusal.

    • unit12medic,

      For what it’s worth, there was an old grouchy ER doc way back when I was getting started that used to routinely chew out medics for using D50. This was back in the stone ages and you had to call for orders on everything. He would routinely deny the D50 request and tell them to start a line of D5W. This would be followed by the fore mentioned buttchewing upon arrival at the ER.

      We do not need to transport every hypoglycemic patient.

      The whole point of this is that I was using D5W on these patients 20 years ago. They came to in roughly the same time, and it was a much more gentle process. The only reason people use D50 is because they want to get a refusal.

      I don’t think that the objection is so much focused on getting a refusal as it is on believing old EMS folklore and on not wanting to change.

      A lot of us want things to be a certain way and not change, but there is no place for that attitude in medicine.

      Patient care requires that we continually change as we learn more about what is best for patients. Resisting that change is about making the lack of change more important than the patients.

      With 10% dextrose we should be able to get the same percentage of refusals as with 50% dextrose. Refusals are more about what is right for the patient, rather than what is right for the crew or the company.

  7. hello i just wanted to ask what is the form to prepear dexstrose 10% from dexstrose 5% and dexstrose 50%..(if i dont have dexstrose 10%)… thank you

  8. Out the gate: I am not EMS. I’ve been in radiology for a little over 20 yrs. I’ve had Type I Diabetes for almost 35 yrs. I’ve always had trouble with hypoglycemic episodes. Lately they’ve been more frequent and more severe.

    I do mobile u/s in outpatient settings. I was driving home from my morning clinic today. I left the clinic at noon. Woke up in an ambulance around 3 pm. The EMTs were great. They asked the typical eval. stuff and then told me that I stopped my car in the middle of the street in a residential area. A resident saw me and called 911. I didn’t feel it coming (most times I do.) I have little to no recollection of events. I never go completely unconscious. I can even answer direct questions up to a point. This makes it difficult for people who don’t know me to realize that something is wrong,

    Anyway, I’ve been the recipient of both D50 and D10 multiple times. I cannot tell you if there is any difference in recovery time because I do not have memories for when I’m not recovered. I can say that when I’ve had D50, it spikes my BG terribly. I usually spend at least half day to get it under control again. I had a similar situation today. The medics started a D10 drip through an 18G. They had already given me oral glucose twice. My BG was still 26. So, in went the scary big needle. I was out of it for the first bag. I became combative and jerked the site loose. The EMT said that he reached over and yanked it the rest of the way out as quickly as he could to prevent extravasation. Then he started a new line in my other arm.

    My husband arrived, and we opted to go home once my BG went up. The medic told me to keep an eye on my arm. He told me there was a risk of necrosis. I had never heard of this before. When I think back to the time they put the line in my Jugular to give me D50, it gives me the willies. There is a lot less meat on my neck than my arms. What if something had happened? Luckily nothing did.

    I bruise very easily. I have a nasty blue/black bruise on the first site about 1.5 inches distal to the AC. It’s sore as the dickens, but bruises are typiically sore. It’s been about 12 hrs ago now. I would NEVER want anyone to jeopardize themselves. I’m not asking for advice. I’m asking for information because I love learning. What are tell tale signs of an issue? Can anything be done to help prevent necrosis after extravasation? When should a patient consult their physician?

    Thanks for the interesting information. Thanks to all of you who work in the field. I don’t think I could do it. I sure do appreciate those of you who can and do.

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