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

- Rogue Medic

Should EMS Still Use 50% Dextrose

Here are some of the possible problems we should be aware of when attempting to inject 50% dextrose (D50W) through a peripheral vein.

WARNINGS

50% Dextrose Injection is hypertonic and may cause phlebitis and thrombosis at the site of injection.

Significant hyperglycemia and possible hyperosmolar syndrome may result from too rapid administration. The physician should be aware of the symptoms of hyperosmolar syndrome, such as mental confusion and loss of consciousness, especially in patients with chronic uremia and those with known carbohydrate intolerance.

The intravenous administration of this solution can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, overhydration, congested states or pulmonary edema.

Additives may be incompatible. Consult with pharmacist if available. When introducing additives, use aseptic technique, mix thoroughly and do not store.

For peripheral vein administration:

The solution should be given slowly, preferably through a small bore needle into a large vein, to minimize venous irritation.

For central venous administration:

Concentrated dextrose should be administered via central vein only after suitable dilution.[1]

The section on symptoms of hyperosmolar syndrome, such as mental confusion and loss of consciousness should not really apply to EMS using 50% dextrose, because this is really only indicated patients who are at least very confused and not able to get sugar through any other means.

How many people will give D50W through a small bore IV?

There is too much work involved in pushing D50W through a catheter that is even as small as 20 gauge. The FDA (Food and Drug Administration) recommendation is good for the patient, but not for the person trying to push this syrup through an itty-bitty 20 g catheter. Do we do what is best for the patient or do we do what makes our job easier?

We do avoid giving the butter and the pancakes, but how much difference is there between the syrup placed on the pancakes and the D50W syrup being pushed through the IV?

How much more difficult is it to push if the D50W is cold?

Put some maple syrup in the refrigerator for an hour. Then try to pour it. Time it.

Leave the maple syrup out for an hour and repeat. Time that, too. Temperature is important in the flow rate, but do we consider that in the winter when we are giving medication that might not be close to room temperature?

Do not microwave D50W to warm it up. Cooked sugar crystallizes and turns to caramel. Microwaving syringes is also not good for safe patient care, although the entertainment value of microwaving a large syringe of sugar should not be underestimated. 🙂

and –

Concentrated dextrose should be administered via central vein only after suitable dilution.

But when we push D50W through a peripheral IV, we act as if there are no risks.

Ask doctors, nurses, and medics you work with – What are the risks with D50W leaking out of the vein?

Infiltration/extravasation/vein blows/whatever we want to call it.

How many are aware of the risks?

How many know how to treat the complications?

Precautions:

. . . .

When a concentrated dextrose infusion is abruptly withdrawn, it is advisable to follow with the administration of 5% or 10% dextrose injection to avoid rebound hypoglycemia.

Solutions containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus.

Care should be exercised to insure that the needle is well within the lumen of the vein and that extravasation does not occur. If thrombosis should occur during administration, the injection should be stopped and corrective measures instituted.

Concentrated dextrose solutions should not be administered subcutaneously or intramuscularly.[1]

When a concentrated dextrose infusion is abruptly withdrawn, it is advisable to follow with the administration of 5% or 10% dextrose injection to avoid rebound hypoglycemia.

We were all trained to avoid causing rebound hypoglycemia, right?

DOSAGE AND ADMINISTRATION

For peripheral vein administration:

Injection of the solution should be made slowly.

The maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. About 95% of the dextrose is retained when infused ata rate of 0.8 g/kg/hr.

In insulin-induced hypoglycemia, intravenous injection of 10 to 25 grams of dextrose (20 to 50 mL of 50% dextrose) is usually adequate. Repeated doses and supportive treatment may be required in severe cases. A specimen for blood glucose determination should be taken before injecting the dextrose. In such emergencies, dextrose should be administered promptly without awaiting pretreatment test results.[1]

10 to 25 gm?

What happened to the protocol dose of 25 gm, regardless of the response of the patient and regardless of the size of the patient?

If I give D50W s l o w l y, and we should realize that D50W should only be given slowly, then I expect the patient to begin to respond before I have given a full 25 gm.

If my patient is awake, but only 15 gm has been given, do I complete the treatment for altered mental status (even though the patient does not currently have indications for treatment under a protocol to treat altered mental status)?

According to this label, giving 25 gm to a 100 kg patient should take over half an hour to avoid having some of the dextrose end up in the urine. Likewise 25 gm should be given over one hour to a 50 kg patient and over 15 minutes to a 200 kg patient to avoid having the dextrose end up in the urine.

But, how much of a problem is this?

That depends on several things, such as kidney function, but we can expect some of the dextrose to end up in the urine. We may not care if the dextrose ends up in the urine, as long as the dextrose passes through the patient, but is that good for the patient?

There are a lot of potential problems with 50% dextrose, but there is a need for something to treat hypoglycemia. Are there other treatments that might be better?

To be continued Wednesday with Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.

Footnotes:

[1] Dextrose (dextrose) Injection, Solution
[Hospira, Inc.]

DailyMed
FDA Label
Free Full Text of Label

.

Comments

  1. 1. Make triple sure the IV is patent.

    2. I have never in my career had a pt tell me the IV burned but a good tidbit to keep in mind.

    3. Always follow up D50 admin with complex carbs. Raid the pts kitchen to find what you can.

    4. Duh, we got bigger problems in EMS, slow news day?

    • Carl W. French,

      1. Make triple sure the IV is patent.

      Why not quadruple sure?

      Why not quintuple sure?

      Another possibility is that we could abandon this tradition and use a less dangerous form of dextrose.

      2. I have never in my career had a pt tell me the IV burned but a good tidbit to keep in mind.

      Since we generally give dextrose to people who are unconscious, or close to unconscious, I did not even mention this. It is much less important than the many other risks mentioned.

      3. Always follow up D50 admin with complex carbs. Raid the pts kitchen to find what you can.

      This is what I generally do, but this is not always practical.

      We use a treatment that is expected to produce a lot more side effects than other treatments we could use.

      Why continue to use D50?

      4. Duh, we got bigger problems in EMS, slow news day?

      I can reiterate what Can’t say, clowns will eat me wrote in response to this comment.

      That would not be satisfying.

      Is there any greater threat to EMS than a system that refuses to change when presented with evidence that the EMS system is harming patients?

      If you can give me the authority to change the problems in EMS, I will have to justify what I do on each day. Maybe eliminating the use of D50 would not be one of the goals of my first week, but I doubt it.

      I will follow this with a post about the research on better treatment than 50% dextrose.

      Based on this comment, should I expect that you are going from blog to blog criticizing them for not addressing bigger problems in EMS because you don’t have anything better to do?

      .

  2. First off, #4? Really? What an uninformed statement. Patients are EMS and without them, we’re nothing. We keep treating them incorrectly and it’ll burn us. Period.

    Secondly, I’ve seen rebound hypoglycemia, I’ve seen extravasation, etc.

    Thirdly, Rogue, how do you administer D50 in your practice? the above mentioned rate? The amount to return to normal mentation? etc?

    • Can’t say, clowns will eat me,

      First off, #4? Really? What an uninformed statement. Patients are EMS and without them, we’re nothing. We keep treating them incorrectly and it’ll burn us. Period.

      Amen.

      Secondly, I’ve seen rebound hypoglycemia, I’ve seen extravasation, etc.

      There is not a lot of good that comes out of extravasation necrosis.

      Necrosis is not a positive, except maybe for a malpractice attorney.

      Thirdly, Rogue, how do you administer D50 in your practice? the above mentioned rate? The amount to return to normal mentation? etc?

      My protocols now state that for a blood sugar less than 60 with Altered Level of Consciousness I use 25 gm dextrose 10% to 50%.

      Why should I use the highly concentrated 50% dextrose, when I can inject the 25 gm dextrose into a 250 ml bag of saline and drip it in at a rate and concentration that is less likely to produce complications?

      If the patient wakes up in about the same amount of time, but using less medication, isn’t that the ideal?

      Medication should be titrated to the least amount that is able to produce the desired outcome (with certain exceptions, such as atropine).

      I used to give 50% dextrose by aspirating for blood return, then slowly pushing 5 ml, then aspirating for blood return, then slowly pushing 5 ml, then aspirating for blood return, then slowly pushing 5 ml, . . . , until I have given 25 gm or the patient is alert. If I reach 25 gm, I reassess blood sugar and consider what is appropriate at that point. If the BGL rose from 30 to 200 and the patient is still unconscious, something other than more sugar is indicated.

      Once the patient is awake, the Altered Level of Consciousness protocol no longer applies. Just as with any other protocol, I do not follow the protocol when the protocol is not appropriate for my patient. Documentation of assessment indicating that the patient is awake and alert should be all that is indicated, but your protocols may not allow that.

      The Altered Level of Consciousness protocol also includes naloxone, which is not titrated to alertness, but to not needing to be treated. Pinpoint pupils with decreased respirations and evidence of opioid use would suggest that naloxone be the first treatment, but I do not continue to give the naloxone just to get to the 0.4 mg dose that the protocol indicates. When the treatment is no longer indicated, I document the assessment that indicates this. Medical command contact may be one way to get around giving mandatory minimums.

      .

  3. I believe the new PA state protocol doesn’t specify a concetration for dextrose.

  4. If you inject 25g d50 into 500cc nss what is the advantage/difference ?

  5. Those pancakes look good.

    I actually just got QA/QI for only giving 1/2 a dose to my patient of D50. Sugar was 30, patient was getting a little loopy with a NIID HX. After patient was more alert and c/o weakness was gone. BGL at 134. Of course protocol sts give full dose and nothing about titrating to patient condition etc.

    Also, I always get into arguments with medics especially new ones about using a smaller catheter at say 20g and they insist that the thick med must be given via 18g at a minimum. The best part is they do it becase their instructor told them that was how it had to be done. I may print out the label pdf and post it in the drug box. Looking forward to the 10% post.

    • Jim,

      Those pancakes look good.

      Yes, they do.

      I actually just got QA/QI for only giving 1/2 a dose to my patient of D50. Sugar was 30, patient was getting a little loopy with a NIID HX. After patient was more alert and c/o weakness was gone. BGL at 134. Of course protocol sts give full dose and nothing about titrating to patient condition etc.

      Your protocols are not written for the best care for the patient. they are written to protect the medical director and the company from the possibility of having to assess the people they hire for competence.

      You understand that we are there for the patient. They think we are there to pat each other on the back – and occasionally to sacrifice one of our own to the protocol gods as a way of appeasing the bad outcome gods, who occasionally seem to conspire with the bad story in the newspaper gods. I am just glad that I am not a hot virgin when these sacrifices to the gods of ignorance and incompetence happen.

      Also, I always get into arguments with medics especially new ones about using a smaller catheter at say 20g and they insist that the thick med must be given via 18g at a minimum. The best part is they do it becase their instructor told them that was how it had to be done. I may print out the label pdf and post it in the drug box. Looking forward to the 10% post.

      The large bore catheter makes it easier for us to push it. I had to waste some 50% dextrose this weekend and decided to see how difficult it would be to push through a 24 gauge catheter. It does work, but it also requires a lot of work.

      .

    • I am diabetic and would thank anybody who titrated the D50 to what I need not follow some stupid protocol (as in cookbook medicine). I’ve never had to have D50 because I can treat myself before I have an issue. Please treat your patient with the nasty jell (if you have nothing else) – juice, milk etc before trying D50 (unless pt unconc) and its complex carbs and protein please not just carbs. If I am treating myself I find that 6oz of orange juice no matter how low I am brings me up to around 120. Oh and people DO NOT put D50 in juice milk etc. It does not absorb in the stomach and will make people vomit 😉

  6. As a Type 1 diabetic for the past 20 years and a paramedic for 13 of those, I am appalled at the lack of knowledge and “black and white” mentality of most field providers. Just as we do with all of our calls, TREAT THE PT! The blood glucose monitor may read 19 mg/dl, but the pt could be sitting there talking to us. Does that mean we start an IV and push D50? Absolutely not! Treat the pt…give them some orange juice or a soda and wait. Yes, I said wait. Of course it’s a lot easier to start a line, get the cbg up to 200-something after giving 25 grams of D50 and get a pt refusal. Ever been on that end of the stick? I have and it’s not pleasant. Titrate to effect…please! I routinely use a 22 gauge IV in a forearm to push D50 for just that reason. I push slow, and as soon as the pt starts to come around, I stop. Most times it only takes 12.5 grams to get to this point. My goal is to keep the cbg under 200 mg/dl. It’s no fun combating a roller coaster of numbers for the next 24 hours. Also, you need to understand what type of insulin they take and how much and when they took it. This is such a vital piece of information that most medics miss. If a pt took 8 units of Novolog (short acting) insulin over 4 hours ago, you don’t need to feed them a massive PBJ sandwich after giving them D50. However, if they just took 12 units 30 minutes ago and they’re at 35 mg/dl, you have a BIG problem. Most diabetics (especially type 1) know more about this disease than you will ever learn in your career. Use them as a resource once they have regained their bearings. Some people are on a pump (as I am) and have a protocol for hypo and hyper events. Some people count carbs and some people take a set dose. Some people are on a sliding scale and some people are not. Trust me, when you have a disease that you deal with 24-7, 365, the last thing you need is a medic lecturing you about how you need to control your diabetes better. Some days we just don’t want to “deal” with our chronic disease and our numbers reflect that. There is so much more to this disease than a number. PLEASE remember this the next time you go on that hypoglycemic pt for the umpteenth time. It might be one of those days where we are just trying to get through the day and we don’t need someone with minimal knowledge of the disease lecturing us.

    On another note, pushing D50 through a 24 gauge is not that big of a deal. Yes, you have to push a little harder than normal, but you’re missing the big picture…this pt is probably unconscious and needs glucose. Remember the saying “any port in a storm”? Well, there you go.

    I’m leaving a lot out of this post because it would take a whole lot of time to cover everything. Did you know that pt’s usually end up taking more insulin as their bottle nears the bottom? Why do you care? Because most people will take that same amount when they open a new bottle. So what, you ask? Insulin is most potent after the seal is broken and becomes less potent as the month wears on. Look to see if the bottle in their fridge has just been opend. If so, this might be the reason they always get hypo at the beginning of the month. (This happened to me. No doctor or diabetic educator ever mentioned this to me.) Also, did you know that someone with a HbA1c of 13 could show signs and symptoms of hypoglycemia with a cbg of 120 mg/dl? How do know what their A1c is? Ask their family members…they sometimes know. Sooooooooo much more than “just push 25 grams of D50”! OK, getting off my soap box now.

  7. I have a q’s about d50..i was given 15g of d50 through a a good iv line..after a day or two..i noticed some of my veins harden…and it still is till this day..its been 3weeks..should i be concern that it can get worst..any cure…

  8. https://www.youtube.com/watch?v=ykYZC57LwRw

    The above video describes an alternative method for infusing Dextrose. I hope it is helpful. Thank you for the opportunity to share this with the prehospital care community.

Trackbacks

  1. […] from yesterday’s discussion of the problems with highly concentrated dextrose – Should EMS Still Use 50% Dextrose we will look at some research – Dextrose 50% is a hypertonic solution of glucose available […]

  2. […] the refusal. Easier for us yes…Easier for them NO. I never claim that I can’t improve  –Read this great article on Dextrose for EMS  Do we need order slips to treat […]

  3. […] from yesterday’s discussion of the problems with highly concentrated dextrose – Should EMS Still Use 50% Dextrose we will look at some research […]

Speak Your Mind