D5W vs NS in D50 administration

[letmesleep]

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.

I like this line, and sometimes thats the only real reason.

[rock_shoes]

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.

We do the same thing using D10W. Hypoglaecemic patients start with a 100mL bolus of D10W with a slow 50mg IV push of Thiamine. If the first 100mL bolus doesn't bring the patient's BGL up enough they get another 100mL bolus. Afterwards the patient is kept on D10W at a 100mL/hr maintenance rate until they are either under the hospitals care or have eaten sufficiently. It has worked extremely well in my experience. The maintenance rate is adjusted up and down based on the size of the patient and subsequent BGL checks.

[HERBIE1]

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.

Kiwi-

What is your average transport time?

[Kiwiology]

Kiwi-

What is your average transport time?

Mine is about ten minutes, some places is over an hour

[kohlerrf]

We are moving away (in my servce) from giving a D50 bolus. We tend to opt for a D10 drip in NS or (D12.5 in D5W) unless the patient is so far gone there is repiratory compromise or the pt has been down for a subtantial time with a GCS of 3 and a dramatically low BG. The untoward lasting effects of taking a diabetic pt with a glucose of say 40mg/dcl who is semiconsious and disorented and bolusing them which results in a BG now of possibly 310 mg/dcl is well documented.

Specifically regarding the question of D5W or NS. I dont think the issue has anything to do with the glycemic state of the patient. I reserve D5W for medicated drips, Dopamine , Cardizem etc... If I am concerned about fluid replacement such as in case of a hyperglycemic pt with poly uria/dipsia tachypnea and a normal End tidal CO2 I would opt for Normal Saline as it is an isotonic solutiion and would hold its water in the vessel. In a hypoglycemic patient who is not hemodynamically compromised I mix D10 in a bag of D5W (it actually come out to be D12.5 but lets not go there). In the case of D50 I beleive it all has to do with the hemodynamic state of the pt and not the glycemic as to your choice of fluids.

Lastly you can always push D50 through a LOK then flush and not have to worry about all this?

[Kaisu]

Lastly you can always push D50 through a LOK then flush and not have to worry about all this?

You better make absolutely sure you have a patent line if you do this.

[rock_shoes]

Kiwi-

What is your average transport time?

I've run transport times that where anywhere from 5 minutes to 2 hours working out of a single station. I would expect Kiwi has faced some of the same type of challenges. Coverage areas can be enormous for some of us.

[tniuqs]

We do the same thing using D10W. Hypoglaecemic patients start with a 100mL bolus of D10W with a slow 50mg IV push of Thiamine. If the first 100 mL bolus doesn't bring the patient's BGL up enough they get another 100mL bolus. Afterwards the patient is kept on D10W at a 100mL/hr maintenance rate until they are either under the hospitals care or have eaten sufficiently. It has worked extremely well in my experience. The maintenance rate is adjusted up and down based on the size of the patient and subsequent BGL checks.

Ah the old D10W vs D50W controversy ... perhaps I could explain why "as a receiver of some Diabetics in ER" and the political and medical complications as this is a big controversy with some services I have come across in our reciprocity BC vs AB deal as of late.

IN BC (looks like Kiwiville too) this is SOP and although if on the BGL is very, very low this does takes some time to bring glucose levels up to therapeutic levels compatible with life BUT more gradually (the newer studies suggest that multiple repeat of highs and lows in BGL in the IDDM patient equate to increased mortality morbidity, well long term)

BUT and a big but this is NOT rationale that BC medical directors used when establishing those "Guidelines" initially for giving D10W as a drip vs bolus of D50W THIS was because the vast majority of PCPs or EMT~I in BC, and as their very few ACPs (advanced care paramedics) were veiamently opposed to ANY IV Push meds for the PCP/EMT level, the concept being "do less harm" OR one error would make precedent and therefore NO PCP/EMT would be allowed, anything other than oral glucose ... just saying it was "pre damage control"

Kaisu, make referance to this in her post about patiency of line ... I will just expound a tad.

Point in fact and the reasons argued at that time ..

Question: so has anyone ever had the pleasure of observing the damage done by a line going interstitial while D50W being pushed, this is rather thick stuff (so is it the line or is it the viscosity of the goo ... good question eh what?) and/or unrecognized because all Diabetics with low BGLs are so very cooperative <insert sarcasm>...

Complications: higher concentrations ie D50W can cause sloughing of tissue necrosis if extravastion sometimes requiring debriding of tissue and grafts, far less damage possible in D10W just dripped, just a bit of political medical history. Now in Alberta during that snapshot in time the EMT level was restricted to oral dextrose, this changed and it only took 12 years ... <again insert sarcasm>.

I was very fortunate to actually visit with rock_shoes (and he was forced to remove them on my porch) te he, and this was a topic amongst many others we chatted over.

What we BOTH agreed upon was the use of slow 50mg IV push of Thiamine in his SOP (BC) BUT this does not occur in Alberta EMT (for Paramedic in AB I use 100mg )so why is this very important ???

Why because there is no ETOH related hypoglycemia out there and NO IDDM have the "occasional highball" either< again insert sarcasm>

http://en.wikipedia.org/wiki/Wernicke-Korsakoff_syndrome

Your mileage may vary ... although Glucagon would be in my best semi informed opinion be the best for first round drug for the EMT but it "costs" too much and short shelf life .... sheesh.

A long winded answer to a simple question in the field if I have a possible cardiac I use D5W due compatability with some meds, I guess I just don't like snowflakes in my drips, NS for most but I do always consider R/L for poly trauma and an extra line in the cardiac because one must always suspect (without an I Stat) that K+ could be a touch low.

cheers

Edited October 29, 2009 by tniuqs

[rock_shoes]

Ah the old D10W vs D50W controversy ... perhaps I could explain why "as a receiver of some Diabetics in ER" and the political and medical complications as this is a big controversy with some services I have come across in our reciprocity BC vs AB deal as of late.

IN BC (looks like Kiwiville too) this is SOP and although if on the BGL is very, very low this does takes some time to bring glucose levels up to therapeutic levels compatible with life BUT more gradually (the newer studies suggest that multiple repeat of highs and lows in BGL in the IDDM patient equate to increased mortality morbidity, well long term)

BUT and a big but this is NOT rationale that BC medical directors used when establishing those "Guidelines" initially for giving D10W as a drip vs bolus of D50W THIS was because the vast majority of PCPs or EMT~I in BC, and as their very few ACPs (advanced care paramedics) were veiamently opposed to ANY IV Push meds for the PCP/EMT level, the concept being "do less harm" OR one error would make precedent and therefore NO PCP/EMT would be allowed, anything other than oral glucose ... just saying it was "pre damage control"

Yup. You speak the truth. The use of D10W in BC (for the PCP-IV level) was initiated for exactly the reasons you describe. ACPs still have the option to use D50W if they feel it is warranted (ie. the more severe hypoglaecemic episodes squint mentioned). Fortunately for our patients it has turned out to be a sound practice. This is one of the few areas where BC’s extremely conservative practices have worked out for the better. How Thiamine managed to sneak into the BC protocols is beyond me, but I’m sure glad that it did.

Kaisu, make referance to this in her post about patiency of line ... I will just expound a tad.

Point in fact and the reasons argued at that time ..

Question: so has anyone ever had the pleasure of observing the damage done by a line going interstitial while D50W being pushed, this is rather thick stuff (so is it the line or is it the viscosity of the goo ... good question eh what?) and/or unrecognized because all Diabetics with low BGLs are so very cooperative <insert sarcasm>...

Complications: higher concentrations ie D50W can cause sloughing of tissue necrosis if extravastion sometimes requiring debriding of tissue and grafts, far less damage possible in D10W just dripped, just a bit of political medical history. Now in Alberta during that snapshot in time the EMT level was restricted to oral dextrose, this changed and it only took 12 years ... <again insert sarcasm>.

I’ve never done a med push into an interstitial line myself but I certainly see your point. The biggest reason for using D10W versus D50W is the lower risk of tissue necrosis. No diabetic has papery thin easy to blow veins right? It’s easy to push syrup through a 22 isn’t it? A long time ago, way before my time, BC was actually considered progressive. Now we’ve slipped so far back we’re at least 10 years behind.

I was very fortunate to actually visit with rock_shoes (and he was forced to remove them on my porch) te he, and this was a topic amongst many others we chatted over.

An excellent visit BTW. We’ll have to budget more time next go around. Unfortunately this last road-trip was a bit of a blitz trip only having 3 days and 2000Km of driving to squeeze in.

What we BOTH agreed upon was the use of slow 50mg IV push of Thiamine in his SOP (BC) BUT this does not occur in Alberta EMT (for Paramedic in AB I use 100mg )so why is this very important ???

Why because there is no ETOH related hypoglycemia out there and NO IDDM have the "occasional highball" either< again insert sarcasm>

http://en.wikipedia.org/wiki/Wernicke-Korsakoff_syndrome

The sad thing is that many PCPs probably don’t even know why we bother with the Thiamine push. We have finally moved to using “Treatment Guidlines” vs. protocols which should reduce the incidence of doing without understanding, but until the big upcoming retirement bubble goes through many will “just follow the protocol”. This isn’t meant as a slight against them in any way. These medics come from an era when any deviation from protocol, even with good reason, was met with harsh discipline. Thinking on your feet was dangerous to keeping your job in some ways so these medics learned to survive as best they could. This makes it extremely difficult for them to accept and implement changes now (ie. strong movement towards more evidence based practice).

Your mileage may vary ... although Glucagon would be in my best semi informed opinion be the best for first round drug for the EMT but it "costs" too much and short shelf life .... sheesh.

Glucagon is in my SOP but I’ve never actually used it. So far, fingers crossed it stays that way, I’ve been able to gain IV access whenever I needed it in hypoglaecemic patients. I understand how it works and why it’s a good option. I’ve just haven’t had the opportunity to put it into practice yet. One important thing to remember with Glucagon is that giving a second 1mg SC or IM dose is extremely unlikely to have much if any effect if the first dose didn’t work. Glucagon essentially breaks down the bodies “emergency stores” (glycogen, the greatest portion of which is stored in the liver). This process (gluco-neogenesis) restores the patient’s blood glucose levels temporarily. If the first dose of glucagon is ineffective the patient’s glycogen stores are already depleted making further doses useless. I prefer not to use glucagon because it means I was able to restore a patient’s BGL without tapping into their emergency reserves.

A long winded answer to a simple question in the field if I have a possible cardiac I use D5W due compatability with some meds, I guess I just don't like snowflakes in my drips, NS for most but I do always consider R/L for poly trauma and an extra line in the cardiac because one must always suspect (without an I Stat) that K+ could be a touch low.

cheers

I wish we carried Ringers on car here. It’s in my SOP just not in our cars. We had a burn patient a while ago who would have definitely benefited from Ringers over NS.

[Kaisu]

I did an IM glucagon on a brittle diabetic with bleeding from the dialysis port. Could not find a line. Glucagon worked very well.