D10: Better For Our Patients

Back in November 2007, an article appeared in JEMS called  Is D50 Too Much of a Good Thing?.  (Unfortunately, I can no longer find the link to it.)

The point was when faced with a hypoglycemic patient, instead of giving them D50 through an IV and risking tissue necrosis and too rapid an absorption of Dextrose, it would be better for the patient to put the D50 in a 250 cc bag (you would have to let out 50 cc first) and then run the whole bag in as D10. The other good part of this is it makes it much easier to titrate to effect. Some patients won’t need the whole D50. (At the time, I couldn’t find the D50 insert, but an internet site suggested D50 needs to be pushed much slower than I think many people push it — as fast as it will push).

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.

I asked a couple brittle diabetics about their preference between the thick syrupy D50 and the more watery D10 and they have said they would prefer getting the D10 to the D50 which often leaves them with a headache and rubbing their veins.

I believe the article referenced the following study done in the Emergency Medical Journal in 2005:

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

Abstract

OBJECTIVE:

To investigate whether 10% dextrose given in 5 g (50 ml) aliquots is more effective than 50% dextrose given in 5 g (10 ml) aliquots in the treatment of out of hospital hypoglycaemia.

DESIGN:

Randomised controlled trial.

SETTING:

Out of hospital patients attended by paramedics from a large UK ambulance service.

PARTICIPANTS:

51 unresponsive adult patients with blood glucose levels < or = 4 mmol/l.

INTERVENTION:

5 g (50 ml) intravenous aliquots of 10% dextrose or 5 g (10 ml) intravenous aliquots of 50% dextrose to a maximum dose of 25 g.

MAIN OUTCOME MEASURES:

To compare for each dextrose concentration the time to achieve a Glasgow Coma Scale (GCS) score of 15, and the dose required to obtain a blood glucose level of > or = 4.5 mmol/l.

RESULTS:

There were no statistically significant differences between the groups with regard to age or sex, median pretreatment GCS, pretreatment blood glucose level, or proportion of patients with insulin dependent diabetes. Following treatment, there were no statistically significant differences in median time to recovery (8 minutes), median post-treatment GCS, or number of subjects experiencing a further hypoglycaemic episode within 24 hours (four per group). The median total dose of dextrose administered was significantly less with the 10% concentration (10% = 10 g, 50% = 25 g, p < 0.001) and median post-treatment blood sugar levels were also significantly lower (10% = 6.2 mmol/l and 50% = 9.4 mmol/l, p = 0.003). There were no reports of extravasation injuries in either group.

CONCLUSIONS:

Dextrose 10% delivered in 5 g (50 ml) aliquots is administered in smaller doses than dextrose 50% delivered in 5 g/10 ml aliquots, resulting in lower post-treatment blood glucose levels. We therefore recommend it as the intravenous treatment of choice for adult hypoglycaemia.

Eventually, due largely to this study, as a region in 2012 ( yes so many years later), we changed our Altered Level of Consciousness guideline:

Dextrose can be given in any concentration. D50, D25 or D10. Dextrose should only be given in the amounts necessary to return patient to baseline. Studies have shown a lower concentration and gradual administration may be better for patients than the standard 25 gram D50 IV push.

Despite that change, I would say in most patients I (and most other medics) continued to give D50, although not always the full 25 grams (this was a positive improvement- myself and many medics started stopping at 12.5 grams for a reevaluation).  Sometimes if the patient had really small veins, I might empty 12.5 grams from the vial and then draw up 25 cc of normal saline to make D25.  I never made D10.

Recently there has been a nationwide shortage of D50.  When we briefly ran out of D50, we were given 500 cc bags of D10 (so the bags had 50 grams of Dextrose in them), and we were instructed to use only enough to bring the patient back to consciousness. 

While we now carry D50 again, this past week I had a patient with altered mental status and a sugar of 40.  We had both D50 and a bag of D10 in our house bag, so we tried the D10.  My partner put an 18 in the patient’s hand, and the D10 ran in easily.  In no time, the patient was alert and talking to us.  He had received just 100 ccs or 10 grams of D50.  We rechecked his sugar, it was 124.  Since we didn’t have a clear reason why he had dumped his sugar (his insulin had been raised three weeks ago, and this was his first problem, he had eaten as regular) we convinced him to go to the hospital.  On the way, when he became a little confused again, we opened up the drip and gave him a little more.

In a recent post, Rogue Medic wrote about the opportunity EMS has to enable the drug shortage to improve our guidelines and our patient care.

Let the drug shortages help us make better patient care decisions

I join him in his call.  I see no reason why we should continue to give D50 when D10 is better for our patients.

Note: I had a hesitation that running a drip of D10 can be time consuming when faced with a small vein.  Many diabetics have poor vasculature and sometimes all you can get is a 24.  If you don’t want to wait for the bag to drip at it’s rate, you can use a syringe to draw up the D10 and just push it until you achieve the desired effect.  Again, better for the patient and better for the patient’s veins.

 

10 Comments

  • Brad Anderson says:

    I have always preferred this method, except it was when we carried D5/NS. It worked great and you were only given what was needed. 1000cc was equal to the amp of D50 and as the article stated you do not need the entire 5g to achieve desired effects. And I can already hear the critics now, ‘but their blood pressure?’. Honestly, I have never seen a normotensive, hemodynamicaly stable adult be affected by an infusion of 500-1000cc. Is it possible, yes, but I have also never had to give over 500cc of D5 to achieve the mental status needed to provide oral intervention. The replacement of D5 to an als unit would suffice, and also save the precious time used to mix the D50.

    Brad Anderson

    EMT-Paramedic (ret.)

  • Brad Anderson says:

    Typo correction: 25g, not 5g

  • Jim A. says:

    Okay how about swapping out all the D50 for D25 and going with that instead? As a start till a full consensus is reached on this issue and new guidelines are established. It would seem to me that inclusion of the NIH section that researches Diabetes and treatments would also be good in reaching that consensus.

  • jason bolt says:

    A 1000 cc bag of D5W has 50g of dextrose not 25.

  • Christopher says:

    Jim A,

    Why start from the idea that D50W has any research behind it being superior to D25W or D10W? In fact, it appears this simple study shows there is no real reason we should use D50W besides its perceived convenience for EMS and hospital personnel.

    The burden should be on D50W to prove why we need something so caustic and destabilizing.

    We’re working to swap out all D50W for D10W at our department and we’re happy to see it go.

  • Andrew says:

    I agree, go with the D10. There is no reason to use D50 other than for the illusion of convenience of the staff. Is that really what we should be focusing on? What about the best treatment for the patients?

  • Geoff says:

    Sounds like a great idea.

  • Timm says:

    While I agree with this, I do have a concern. A good chunk of the hypoglycemics I deal with refuse transport. A couple have been transported (no IV could be started due to poor/beat up veins) and became very upset with the ambulance service. How long would it take to run the D10 solution in to these patients? Would refusal still be an option?

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