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]


Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.

Also posted over at Paramedicine 101 and at Research Blogging.

Go check out the rest of the excellent material at both sites.

Continuing 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 in prefilled syringes containing 25 g glucose in 50 ml water (IMS mini-jet, International Medication Systems (UK), Leatherhead, Surrey, England). In south-east Wales, at the time of this study, it was administered intravenously in 5–10 g (10–20 ml) increments, titrated against effect after confirming hypoglycaemia by capillary or venous blood sugar level.[1]

This is a bit different from the American protocols I am used to, which generally have only specified a dose of 25 gm followed by reassessment of blood sugar and a possible second dose or a different treatment. This does appear to be similar to the way that I have treated unconscious hypoglymic patients – pulling back on the plunger to assess for blood return (an indication that the IV catheter is properly placed within the vein) and slowly pushing, but they are giving twice as much as I would at any single time.

An important point is that the participating EMS agencies realize that supplementing the patient’s dietary dextrose with intravenous dextrose means we are giving a drug and that drug should be titrated to effect. The same is true of supplemental oxygen. We need to recognize that these are drugs that have significant side effects. For too long, we have ignored these side effects and have been irresponsibly presuming that these treatments are harmless, in spite of risks that appear to include permanent disability and death.

This randomised controlled trial aimed to compare the efficacy and safety of 5 g aliquots of 10% and 50% dextrose in the out of hospital treatment of adult hypoglycaemic patients.[1]

5 gm of 10% dextrose = 50 ml.

5 gm of 50% dextrose = 10 ml.

To ensure that the dose of 10% dextrose was measured accurately, the paramedics used a syringe attached to a three-way tap to draw up 50 ml aliquots from a 500 ml infusion bag attached to a giving set. The 10 ml aliquots administered to the 50% dextrose group were measured using 5 ml calibration markings on the prefilled syringes. The paramedics were instructed to administer the 5 g bolus and wait for one minute before administering subsequent aliquots, until either the Glasgow Coma Scale (GCS) score had returned to 15 or the maximum cumulative dose of 25 g of dextrose had been administered. Time taken to regain GCS 15 was calculated from the time the first incremental dose was administered.[1]

Due to the confused or unconscious state of hypoglycaemic patients it was not possible to obtain informed consent from the participants prior to recruitment into the trial. Instead, when they were recovered and oriented after treatment, the paramedics informed them that they had been recruited for a study that was comparing the efficacy of two different concentrations of dextrose. Each participant was given an information pack describing the trial with a form and preaddressed envelope so that participants could withdraw their data from the study at any time. Ethical approval was obtained from the Bro Taf Health Authority Local Research Ethics Committee.[1]

Amazing. None of the whining about withholding the Standard of Care that discourages evaluation of treatments that have become Standard of Care because they are traditional treatments, rather than safer and more efficacious treatments than other treatments.

Sample size
Following a pilot study, it was established that a total sample size of 50 was required (25 subjects per group) to detect a three minute difference between the groups in a return to full consciousness (GCS 15), with power of 0.85 and α of 0.05.[1]

That is the big deficiency of this study. The sample size is too small, unless the only reason for studying this is to determine if the difference in time of the treatments is statistically significant.

Is this due to a mistaken concern that the availability of the paramedic to the next patient, and the possible delay in response time, is more important than the complications of treatment? Then there are many treatments that we should abandon for taking too much time. Why treat these patients at all, when we can just throw them in the ambulance and beat feet to the hospital?

On the other hand, if we accept that the treatments provided by paramedics are expected to be both efficacious and safe, then the size of this sample does not evaluate that question.

To turn the question around, is the current treatment of hypoglycemia with 50% dextrose safe enough?

By switching to a less concentrated dextrose solution, do we significantly improve safety?

This is a much more important question than whether switching to 10% dextrose for hypoglycemia will slightly delay the patient’s return to consciousness or slightly delay the paramedic’s return to availability. If there were some evidence that paramedic response times made a difference in outcomes, small differences in treatment time might be important.

While the difference in treatment time is subtle, the difference in concentration of the solutions is not remotely subtle. This is where the focus of the study should be.

Would a 1% rate of tissue necrosis be important?

If the rate of tissue necrosis from infiltration is 1% with 50% dextrose, is this study designed to evaluate that?

Would a 1% rate of rebound hypoglycemia be important?

If the rate of rebound hypoglycemia is 1% with 50% dextrose, is this study designed to evaluate that?

Is there a significant difference in complications between 10% dextrose and 50% dextrose?

If there were a significant difference in the complications, wouldn’t it justify a significant difference in treatment time?

It may seem reasonable to conclude that I am not happy with the research. That is not true. My criticism of the research that has been done is insignificant compared to my criticism of the lack of research by others.

Our criticism should be addressed to the medical directors who give hundreds of doses a year of 50% dextrose through their paramedics with no assessment of outcomes and no consideration of research to demonstrate efficacy and safety. Further criticism should be addressed to the FDA (Food and Drug Administration) for discouraging emergency research. Other criticism should be directed at the administrators and lawyers who discourage us from even asking if we are harming our patients with the Standard of Care.

C. Moore and M. Woollard deserve our thanks and praise for raising the question of why we are giving such highly concentrated dextrose without evaluating the comparable safety and efficacy of much less concentrated dextrose solutions.

After all of that ranting, what are the results of the study?

Time on scene was moderately higher for the 10% dextrose group, and paramedics rated administration of 10% dextrose as being slightly less easy than for the 50% solution. However, neither finding reached statistical significance. There were no reported incidences of extravasation in either group.[1]

The difficulty is due to the method of administration used in this study. There are many other methods that might be used. We can expect that some innovative paramedics will come up with acceptable ways of giving 10% dextrose that are not slightly less easy than giving 50% dextrose.

Both the median total dose of dextrose administered and post-treatment blood sugar level were significantly higher in the 50% group, and these subjects were more likely to have received the maximum permitted dose of 25 g (table 2).[1]

Imagine if we found out that using a different concentration of morphine produced a statistically significant difference in the total dose of morphine given. Morphine is a very safe drug that is only perceived as unsafe by inexperienced medical directors and by other inexperienced people.

Or substitute fentanyl, or diazepam, or lorazepam, or midazolam, . . . . for morphine in that sentence.

Fentanyl, diazepam, lorazepam, midazolam, . . . are very safe drugs that are only perceived as unsafe by inexperienced medical directors and by other inexperienced people.

An exploratory analysis of patients without a maximum GCS score of 15 following treatment is shown in table 3. Although all three patients had euglycaemic post-treatment blood sugar levels, all required hospital admission. One of these patients was suspected of being under the influence of illegal drugs, one was a known alcoholic, and one had a serious intercurrent urinary tract infection.[1]

Look at the blood sugar levels.[2]

11.4 mmol/l is 205 mg/dl. Would this patient continue to be treated with dextrose, if the patient had been receiving 50% dextrose?


9.7 mmol/l is 175 mg/dl. Would this patient continue to be treated with dextrose, if the patient had been receiving 50% dextrose?


8.7 mmol/l is 157 mg/dl. Would this patient continue to be treated with dextrose, if the patient had been receiving 10% dextrose?


The patients did not become alert, even though their blood sugar levels increased well beyond the normal range. These do not appear to have anything to do with either concentration of dextrose.

Two of the subjects contacted by the researchers after treatment reported that before the study they had often had difficulty bringing their blood glucose back to their expected usual level after being treated by paramedics using 50% dextrose. This might imply that the lower cumulative doses administered with the 5 g (50 ml) aliquots of 10% dextrose could assist patients in controlling their post-treatment blood sugar levels. Evidence suggests that administration of dextrose can have a detrimental effect on patients at risk of cerebral ischaemia, such as victims of stroke, cardiac arrest, or head trauma.7 Avoidance of hyperglycaemia has a neuroprotective effect and reduces mortality and morbidity in the critically ill.14 15 The relatively lower post-treatment blood sugar levels associated with the use of 10% dextrose administered in 5 g (50 ml) aliquots may, therefore, offer a safer option for the treatment of hypoglycaemia in these categories of patient.[1]

Are we harming our patients by giving such high doses of highly concentrated dextrose?

Does 50% dextrose predispose patients to adverse effects?

If we base our answers on what we know about pathophysiology (examples given in the above quote), we should conclude that the continuing use of 50% dextrose is not justifiable.

We use our knowledge of pathophysiology to justify treating cardiac arrest patients with epinephrine, amiodarone, and lidocaine.

Why do we use our knowledge of pathophysiology to support giving treatments that are not based on evidence to patients who will probably not survive their cardiac arrest, when we do not use the same knowledge to limit ourselves to safer and readily available treatment for hypoglycemia who are expected to survive their hypoglycemia?


[1] Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.
Moore C, Woollard M.
Emerg Med J. 2005 Jul;22(7):512-5.
PMID: 15983093 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central           Free Full Text PDF Download from PubMed Central

[2] What are mg/dl and mmol/l? How to convert? Glucose? Cholesterol?
Internet FAQ Archives

To convert mmol/l of glucose to mg/dl, multiply by 18.

To convert mg/dl of glucose to mmol/l, divide by 18 or multiply by 0.055.

Moore, C. (2005). Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial Emergency Medicine Journal, 22 (7), 512-515 DOI: 10.1136/emj.2004.020693


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.


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?


. . . .

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?


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.


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

FDA Label
Free Full Text of Label