The roll of D5W in CHF patients

[firefighter523]

Someone please help with the mechanism of D5W administration in CHF patients. I have Google'd it numerous times and came up with nothing. We got in an argument over it after class, and now I am totally confused!!

[AZCEP]

You are going to have to give a little more information as to what your problem is.

D5W isn't used very much for anything. More commonly, you will see it used as a mixing solution for medication infusions. For administration, you will be giving it IV.

[firefighter523]

Sorry, I was referring to the osmotic pull of fluids, into or out of the vascular space. I know albumin is a heavy protein, and thus it pulls interstitial fluid back into the vascular space, (reduction of edema). My question is, does the osmotic pull of sugar pull fluid into the vascular space, or vice-versa (to reduce preload in the CHF pt). Our protocols suggest, if we have to hang fluid, it should be D5W.

[Ridryder 911]

Wow !.. Haven't seen D5W used on protocols in about 20 years! The theory of using D5W in the early years was because the glucose molecule was easily crossed the cell membrane, thus medications etc. should be used for such. This theory has basically been abandoned.

Since D5W is still really considered an isotonic solution (5g of glucose per 1000ml of dilute) dependent on resource some might classify it slightly hypertonic. AHA and the ECC changed solution(s) recommendation back in the early 80's of using NSS. It is not so much of what fluid you use, but how much you are infusing. People were scared of using NSS because of the sodium level and actually increasing CHF, but closely monitoring fluid levels is the main importance. You do not have enough glucose in D5W to cause osmotic diuresis or should not be giving that much, you will be drowning your patient and causing an overload.

Like my EMS, most EMS only carry D5W for the ability to mix Cordorone and Dialntin purposes. It is foolish to spend extra money for extra fluid (s) when really most EMS have a short patient time. Again the amount of fluid (i.e KVO <25 ml/hr) is not going to change anything. In fact most ER's, CCU, etc have promoted not using any fluid and maintaining saline lock for med administration. If the patient is severely over hydrated, they may be placed on fluid restrictions IV & p o.

Besides, the treatment should geared at increasing oxygenation at cellular level. I am wondering does your service utilize BIPAP, use of Lasix or Demadex, Nitrates in CHF. This would promote a faster and more therapeutic regime & decrease preload thus afteroad. If not, I highly suggest your protocols be reviewed and brought up to national standards.

Again, I doubt your protocol for using D5W for anything but to keep the vein open and the amount you will be giving is really of no concern in changing osmalrity changes. You could be hanging Ringers if it is 10 -20 ml an hour and if you only administered 15 ml you would not see a change (although I would not recommend that .. the ER doc would think your crazy)

Be safe,

R/R 911

[firefighter523]

Thanks Rid, I know that fluids are NOT the answer, but one of our students got a bad eval for not hanging D5W in a CHF patient. We do use, up to 3 nitro, 80 of lasix, and of course CPAP. On command we have, albuterol, morphine, and dopamine. Thanks for the info. I like the idea of a lock also.

Kevin

[Ridryder 911]

Cool.. it is a shame that your guys got in trouble.. it appears that medical control maybe a little anal on following protocols rather than treating the cause and effect. I do understand....

R/R 911

[firefighter523]

No, he got a bad eval from the precepting paramedic, and he was just wondering why.

[Dustdevil]

No, he got a bad eval from the precepting paramedic, and he was just wondering why.

Sounds like the preceptor is an anal protocol monkey, and probably a very new paramedic, with a poor educational background and insufficient experience to understand the relevant pathophysiology or practical alternatives. If your ambos carry D[sub:46558d147a]5[/sub:46558d147a]W, then this was a perfectly rational and acceptable use of it. It's like arguing the benefits of a venturi mask over a nasal cannula. It's stupid. There's just no significant difference. Both get the job done, and neither of them creates a risk.

I would give the preceptor a bad evaluation and send him back to school.

[AZCEP]

I would suggest asking the preceptor for some clarification. I would bet that the answer they give will be along the lines of, "That is what it says in protocol, so that is what we do."

This is the type of psycho-motor monkey bologna that gets us into trouble in the first place. I am encouraged that, as a student, you are taking the time to try to understand the process at hand, though.

As Rid already said, you will not be using enough fluid to actually make a difference when dealing with the osmotic movement of fluids. In the event you are, D5W would draw fluid out of the interstitial space due to it's slight hypertonicity. This little bit of hypertonicity would not be enough to have a clinically significant effect. If you gave enough to get the effect that you mention, you would end up drowning the patient anyway.

I would also recommend asking the medical direction for some updating of the protocols, or wait until you are done with school, and decide to go somewhere else.

[Nate]

I was kind of wondering the same, I've never seen any of the ambulances around here use it.