D5W vs NS in D50 administration

[sirduke]

Just wondering, our service uses a Normal Saline drip when administering D50, however, our neighboring county uses D5W for the same thing. One of our part-time medics, who has been a medic for about 18 years is very vocal in his opinion that we should be giving D5W.

When I went to paramedic school we were taught to use Normal Saline, however the students we are precepting have been taught to use D5W.

So I thought we'd open this up for discussion, I searched the forum, but didn't see any topic directly related to this.

Can't wait for Dusty to weigh in on this one, ought to be a lively debate.

[P_Instructor]

I guess it may boil down to what your Medical Director wants. We use NaCl for everything because of capatability (note: usual transport time less than 20 mins)

[chbare]

Does it really matter? If it's a choice between using NS or D5W as a vehicle for D50, I cannot see where the conflict is coming from. If we are talking about tonicity, electrolyte imbalance, and solvent/solute shifting and the implications for patients with various conditions, we have a discussion. However, I dare say the topic at hand does not relate to such concepts. Seems like the "I was told this and he was told that" situation. The best thing to do is ask the following questions:

1) What was the reasoning behind using NS when you were taught?

2) What was the reason for teaching D5?

If the answer was something like,"because they said or medical director preference" a comprehensive argument or discussion does not exist.

Take care,

chbare.

[rock_shoes]

I think a strong case could be made for choosing D5W over NS in this circumstance. If for whatever reason you are unable to "feed" your patient after administering the D50W to restore BGL, using D5W would allow you to employ a "glucose maintenance rate". D50W is "used up" by the body quickly. Maintaining a stable BGL with D5W would be preferable to the "shock and awe" of pushing more D50W in my opinion.

[chbare]

I think a strong case could be made for choosing D5W over NS in this circumstance. If for whatever reason you are unable to "feed" your patient after administering the D50W to restore BGL, using D5W would allow you to employ a "glucose maintenance rate". D50W is "used up" by the body quickly. Maintaining a stable BGL with D5W would be preferable to the "shock and awe" of pushing more D50W in my opinion.

That is a consideration; however, consider the following:

D5W has 5 grams of dextrose per 100 ml.

An eight ounce glass of cranberry juice has about 36 grams (~15 grams in 100 ml)

Therefore, you would have to run your D5W at a rate of 300 ml/hr just to give the dextrose of a glass of juice.

While this is doable, I am not sure that doing this is all that helpful for transport times of less than 20 minutes. In addition, once the dextrose is utilized, free water is left behind. This leaves a rather hypotonic solution behind. Not the greatest solution for already swollen cells, cerebral edema, or stroke patients. Since stroke should be on your differential list for altered mental status, even in hypoglycemic patients, you will need to be very careful and utilize good clinical decision making if you want to go down this route.

Take care,

chbare.

[mobey]

That is a consideration; however, consider the following:

While this is doable, I am not sure that doing this is all that helpful for transport times of less than 20 minutes. In addition, once the dextrose is utilized, free water is left behind. This leaves a rather hypotonic solution behind. Not the greatest solution for already swollen cells, cerebral edema, or stroke patients. Since stroke should be on your differential list for altered mental status, even in hypoglycemic patients, you will need to be very careful and utilize good clinical decision making if you want to go down this route.

Take care,

chbare.

I like your post chbare.

I believe there is a time and place for D5W as well (as you implied). For example, a septic hypoglycemic, dehydrated hypoglycemic, etc.

While this is doable, I am not sure that doing this is all that helpful for transport times of less than 20 minutes.

Agreed.... kind of.

I have began to think of my job as more of a continuum of health care than it's own entity. That is to say, if the pt is likely going to get a D5 drip (or 12lead, or IV, or..or...or.) when I arrive at the hospital then I should perform those assessments/interventions either onscene, or enroute.

Ya, we could start NaCl and have the hospital change it to D5W, or we could just start with D5W.

Edit: I think I misunderstood your post...... I think you were talking about running 300+mls of fluid, not witholding D5W due to transport times.

Oh well, disregard the above.

[sirduke]

I was taught to hang NS, and the protocol where I worked then, as well as the protocol where I work now, is NS, however, I also work part-time at another service which has D5W in their protocol, so when there, I use D5W.

The reason for posting this in the first place was to bring up the fact that there seems to be no standard being taught that is consistant from one school to another.

When I was a paramedic student, this same Paramedic asked me what fluid I'd hang when administering D50, and when I told him NS he threw Hell. And when I informed him, as did one of my classmates, that we were taught to use NS, he informed us that we as well as our instructor were idiots. He even went on to call our instructor and raise hell with her.

Our current crop of students are being instructed to hang D5W, and one of them questioned me while riding along, when I hung NS.

Anyrate, still waiting for Dust to slip in, tell us all Paramedic schools suck, grumble a bit, and then enlighten us all.

I've scoped this out on the Net, read all the pros and cons I could find, and still don't have a definite answer as to which is best.

[Aussieaid]

I am not sure where the idea of hanging D5W comes from when giving D50 boluses. I understand the theory of wanting to maintain the glucose level after giving a bolus but in the hospital they rarely run a straight D5W drip as it becomes hypotonic as someone said. They would usually change it to a dextrose/saline combination drip in the hospital anyway if they want to continue giving dextrose (and this is usually placed on a pump where you have strict control over how much they are getting). It is better to just give repeat dextrose boluses in the prehospital environment. D5W is only really used to dilute drugs that are incompatible with saline and where glucose control isn't an issue (like potential head bleeds as was also mentioned). The reason you give fluids with the D50 is to dilute it so it isn't as caustic on the veins. Adding more dextrose to the mix is actually defeating the purpose as it will make the solution even more hypertonic (adding more dextrose). For EMS purposes the best thing is to use saline with which there is no problem giving boluses when you need it and it is more often compatible with any other medications you want to give. D5W should not be used in place of saline/LR as regular IV fluids.

In the case of glucose control more is not always better. Yes, you want to maintain a decent blood level but it is really easy to overshoot and that comes with a whole new set of problems. That is why they have very strict glucose level parameters in the critically ill patients especially those with head bleeds, sepsis, pediatrics, neonates etc. They often start insulin drips to control the levels in the ICUs even on non-diabetics and the desirable range is pretty narrow.

Just my opinion for what it's worth. (Hopefully at least a penny )

Edited October 9, 2009 by Aussieaid

[chbare]

Did you ask these paramedics to give their reason? When you ask somebody to articulate their stance and give evidence to support their claim, their argument is deflated. There is no standard because there is no standard. There exist no compatible issues, therefore the decision is based on protocol and sound clinical decision making. Unfortunately, it would seem students are taught " if you give this hang that" cook book medicine. Therefore, taking decision making out of the equation and simply telling people to give this or that is easier than taking the time to actually explain how these fluids work.

Take care,

chbare.

[Kiwiology]

My question would be why are you adding anything to giving glucose IV? Are you flushing the bolus because it's in ampoule form?

I suspect we have not used 50% dextrose since about 1999 or there abouts. Our service uses 10% glucose IV that comes in 500ml bags and does not require a flush.

Edited October 9, 2009 by kiwimedic