2015-08-22 - Medical Tidbits: Is D50 too much of a good thing ???
In this month’s medical tidbit we are going to look at hypoglycemia and treatment of hypoglycemia (ultimately are the guidelines appropriate ???)
Attaches is a randomized control trial on D10 versus D50 treatment and showed that D10 caused less hyperglycemic events for patients that were hypoglycemic. Other article of importance is a powerpoint presentation given at the national association of EMS physicians this past January (http://www.naemsp.org/Documents/2015%20Annual%20Meeting%20Handouts/SAT%20310%20Rostykus.pdf)
If we look at the science behind our blood sugar
Total blood volume is 70 ml / kg
Average blood glucose level is 100 mg / dl
Total body glucose is 70 mg / kg
Conclusion we have approximately 5 grams of glucose as an adult
D50 is 25 grams / 50 ml or approximately 5x the total amount of glucose in our body.
The GLUT transporters have the ability of taking up maximally 6 mg / kg / min or about 0.006 g / kg / min (this is 0.36 g / kg / hour). The IV D50 dose that we give is:
Adult 0.33 g / kg / 1 – 3 minutes (depending on how fast administered)
PALS 0.5 - 1 g / kg / 1 – 3 minutes
Conclusion – we give about 20 times more glucose than the glucose transporters can handle which in turn floods the body with excess glucose.
Is this bad ???
Multiple articles show that having elevated blood glucose levels puts additional stress on the body. Also puts patients at risk of infection along with extravasation of the glucose into the surrounding tissue (if the IV blows) causing tissue necrosis. Has been shown to cause localized phlebitis and destruction of blood vessels. There is a correlation between glucose metabolism and iron absorption along with causing hypokalemia (high levels of glucose will activate the insulin receptors and potassium is pulled into the cells)
Summary of the attached article
Emerg Med J 2005; 22:512–515. doi: 10.1136/emj.2004.020693
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.
Randomized controlled trial.
Out of hospital patients attended by paramedics from a large UK ambulance service.
51 unresponsive adult patients with blood glucose levels < or = 4 mmol/l.
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.
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.
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.
What does this mean. The ideal treatment for our patients are with 50 ml aliquots of D10 (this gives you 5 grams per dose, or give 10 ml of D50 – again 5 grams of dextrose). The benefit of giving the D10 again is that it is less corrosive to the blood vessels and less risk of phlebitis. Current guidelines will not change .. but giving you the literature of where things are going in the future.