Transmucosal glucose and evidence based medicine

[Asysin2leads]

Just a quick poll here, how many people's services have protocols, standing orders, or unwritten general operating procedures that involve placing oral glucose between the cheek and gums of a hypoglycemic patient that is not able to follow commands? I'm asking for a very specific reason.

You see, when I first started out, there was this debate of whether to use the oral glucose in that fashion or not. One camp said yes, that the amount of glucose absorbed was enough to raise the BGL in a hypoglycemic patient. The other camp, of which I belonged to said no, that's not a good idea, introducing a foreign, sticky substance into the orophaynyx of an unconscious person was just asking for airway trouble. Debates were entertained. Arguments were had. Wars were waged.

Through the years I have come across services that recommend this procedure for administration of oral glucose, and others that specifically forbid it. So I decided one day to see if anyone had ever done a study about its effectiveness.

Lo and behold, the good people at the Journal of the American Medical Association did a study, and found that the amount of glucose absorption through the buccal membranes was less than 0.05 mg. In other words, it doesn't work. The title of the article, "Bioactivity of Instant Glucose, Failure of Absorption Through Oral Mucosa", was a big tip off. (Here's the link in case you don't believe me. http://www.ncbi.nlm.nih.gov/pubmed/691147 )

But here's the kicker: This study was done in 1978! Why in then name of all that is holy would anybody be arguing about this 30 some odd years later? How does that work? Really smart people did a lot of work and provided some conclusive evidence, some of the most conclusive evidence I've seen about a debated procedure. What hope is there for us to move into evidence based medicine when even when a conclusive study is done, the results are ignored? I don't get it.

[Kiwiology]

Our preference here is to orally give 10% glucose drawn out a 500ml IV bag into a 20ml syringe

If that doesn't work either 10% glucose IV for Paramedic and above or Technicians have glucagon

I'd rather give somebody some glucagon personally, less traumatic than shoving a drip in only to leave them at home

Edited April 14, 2012 by Kiwiology

[paramedicmike]

We talked about this at one of my clinical sites recently. The sheer volume of studies that come out yearly can make it difficult for something like the study you referenced to get a lot of attention. Given the lack of internet based search capabilities in 1978 that slows the research process down even more. With all that it can be difficult for something that may be considered even simple to come to light and even longer for it to gain traction and affect practices.

[mikeymedic1984]

Because in 1978, we did not have any other means, or at least I did not. I cant remember what year glucagon was introduced to my rig, but I know it was not the first few years. So between let them die, or put some goop in their mouth, there was not many options. And remember in 1978 and most of the 80s there was no internet to find such obscure studies, so you would have had to subscribe to this publication to see this study.

[ERDoc]

And since it was done in 1978, no one doing an internet search today will even look at it (except for asys apparently, lol).

[croaker260]

If you really want to gove a medicaion via a mucosal route...for what ever reason, then there is one route where you can give large volumes and NOT worry about aspiration....

Seriously though, it can be done. Just ask me about the PR Snickers Bar....

Edited April 14, 2012 by croaker260

[ERDoc]

Are there any studies to support the rectal route? Wasn't this one of crotchity's favorite things to talk about, rectal glucose?

[Kiwiology]

Are there any studies to support the rectal route? Wasn't this one of crotchity's favorite things to talk about, rectal glucose?

From the late eighties up until about 2003 it was standard practice for the then-named Advanced Care Officer (Paramedic) to carry PR stesolid (diazepam) for seizures in addition to IV/IM midazolam

Apparently the diazepam suppository was "very easy" to slip in ... I'm just not going to think about it

[ERDoc]

Ah, but we are talking about glucose uptake. Diastat is still very common around these parts.

I was able to find a few other articles on the oral glucose issue.

http://www.ncbi.nlm.nih.gov/pubmed/2310277

Edited April 14, 2012 by ERDoc

[Kiwiology]

Yeah but I couldn't resist.

Now I confuse ... you're giving them oral glucose to "absorb" through the oral mucosa? How interesting; seems like a bit of a waste of time; oral glucose paste is awfully sticky muck that does not lend itself to having a structure well suited for absorption; it's not you'd atomising a bit of midaz up their snoz or something.

Around here a patient is given 20ml of glucose if they can swallow it hmmm