# Reasons NOT to Switch to D10



## Tigger (Sep 4, 2015)

This article recently appeared in my newsfeed. http://epmonthly.com/article/d10-may-be-better-than-d50-for-acute-hypoglycemia/

For a time, we were unable to order D50 prefills, so we switched to 250ml 10% Dextrose bags. I only gave it twice (its in the EMT scope in Colorado), but both patients mentioned that it was not as harsh. N=2 there, though I have heard similar comments from other providers patients. It's also the same price as D50 prefills and would negate having to carry D25 as well. 

Is there any reason to not push for only stocking D10?


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## teedubbyaw (Sep 4, 2015)

I don't see a reason not to. D50 via IO is a PITA anyways.


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## DPM (Sep 4, 2015)

I worked for a D50 agency and interned with a D10 agency. Aside from not being able to push it through a lock, there's no downside. Our protocol was to give the first 200cc, reassess, then give the remainder if BG was still low. 

Only speaking from experience, but I didn't see a significant or noticeable time difference between the two. I thought it was weird that with a BG of 59 or a BG of 8, we still gave the same amount. I preferred titrating my dose to avoid sudden hyperglycaemia.


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## Tigger (Sep 4, 2015)

teedubbyaw said:


> I don't see a reason not to. D50 via IO is a PITA anyways.


Indeed it is. 

For better or worse our non-ambulance EMTs can now start IOs and give dextrose as well. I'm picturing some sort of horror show one of these days when we have a forty minute response to a diabetic problem and ten call a year ricky rescue is chasing the patient around brandishing an IO gun shouting "ya'll will comply!"


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## TransportJockey (Sep 4, 2015)

Gave D10 close to a dozen times and myself and other medics at my old AMR op had such better results that even after the shortage was over, we stocked nothing but D10 and had protocols changed accordingly


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## Tigger (Sep 4, 2015)

TransportJockey said:


> Gave D10 close to a dozen times and myself and other medics at my old AMR op had such better results that even after the shortage was over, we stocked nothing but D10 and had protocols changed accordingly


We wouldn't have to change anything either, our protocol just says IV Dextrose at 1g/kg until mentation improves, then check BGL and evaluate.


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## DesertMedic66 (Sep 4, 2015)

We switched from D50 to D10 about a year ago (you can still find some D50 on the units). Our medical director only wants us to be carrying the D10. The reasons why (if I remember correctly) is that you don't have to dilute it for pedis and it's better if you give it to stroke patient than D50.


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## TXmed (Sep 4, 2015)

D10 is great. I used it more times than I can count at my old job. Even through a 24g its starts working when going in. It helps keep them from vomiting, easier on the veins, and helps prevent reflex hyperglycemia because the body can adjust to it easier.


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## Chewy20 (Sep 5, 2015)

All we carry is D10, switched for the same reasons Txmed described.


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## Grozler (Sep 5, 2015)

My old job switched from D50 to D10 and everyone swore it wouldn't be as effective as D50 due to a protocol change. After a few months, everyone I talked to had good things to say about it. Now at another place that does D50 but is pretty old school and people look at me like I'm from Mars when I mention D10. Or something crazy like an Amiodarone drip after ROSC post VT arrest.


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## triemal04 (Sep 5, 2015)

Grozler said:


> My old job switched from D50 to D10 and everyone swore it wouldn't be as effective as D50 due to a protocol change. After a few months, everyone I talked to had good things to say about it.


It's always funny when someone says that.  Because you know...the sugar in D50 is different than the sugar in D10...


> Now at another place that does D50 but is pretty old school and people look at me like I'm from Mars when I mention D10. *Or something crazy like an Amiodarone drip after ROSC post VT arrest.*


Maybe because it's not needed...


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## Carlos Danger (Sep 5, 2015)

Why bother with a "switch" when you can just squirt the D50 into a 250 or 500 bag that you already carry?


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## NomadicMedic (Sep 5, 2015)

Remi said:


> Why bother with a "switch" when you can just squirt the D50 into a 250 or 500 bag that you already carry?



They looked at me like I was INSANE IN THE MEMBRANE when I did that here. (Why you tryin' to dilute that dextrose Esse?...)

I always dilute d50 in a bag with brittle diabetics. Not exactly protocol, but sugar is sugar. Document a concurrent administration of 25g of Dextrose and 500ml of NS.


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## 18G (Sep 5, 2015)

I am a fan of D10. There are many benefits and it carries reduced risks. Efficacy of D10 vs D50 has been proven the same. 

This article lays out all of the supporting reasons to opt for D10 (Academic Life in Emergency Medicine)

Another article posted 8/27/15 in Emergency Physician Monthly outlining the benefits of D10 over D50

STUDIES: 
Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial 

Dextrose 10% in the treatment of out-of-hospital hypoglycemia (California Contra Costa County Emergency Medical Services (EMS) system)


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## Chewy20 (Sep 5, 2015)

Remi said:


> Why bother with a "switch" when you can just squirt the D50 into a 250 or 500 bag that you already carry?



Less steps, same result?


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## DesertMedic66 (Sep 5, 2015)

Remi said:


> Why bother with a "switch" when you can just squirt the D50 into a 250 or 500 bag that you already carry?


Or you can be my service and only carry 1000 or 50 bags with nothing in between :/


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## Carlos Danger (Sep 5, 2015)

Chewy20 said:


> Less steps, same result?



But if you already have a bunch of D50 and carry IV bags anyway, it could mean carrying fewer drugs.


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## bizzy522 (Sep 6, 2015)

D50 seems to be overkill. I usually only give 12.5g vs the whole amp, followed with d5w tko. I'd be interested to try a 10% solution.


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## Tigger (Sep 7, 2015)

Remi said:


> Why bother with a "switch" when you can just squirt the D50 into a 250 or 500 bag that you already carry?


Eventually we will run out of D50 amps in the supply room, the replacements could certainly be D10. D10 premix bags are also cheaper than a D50 amp and a 250NS bag used concurrently. The easiest justification is usually financial, for better or worse.


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## TransportJockey (Sep 7, 2015)

And we rewrote protocols because we were out. This is back when prefills were on backorder for months.  We went with D10 rather than vials of D50


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## NPO (Sep 12, 2015)

I specifically spoke to our medical director about the switch to D10 from D50, after bring it up in medic class and my instructor knowing nothing of the new trend. 

He cited several reasons, including recent shortages, availability for pediatric patients (No D50 for peds), less risk of tissue necrosis, and a simpler protocol that meets all patients rather than one adult and one ped, in addition to the known benefit of not spiking BGL. 

Our current protocol is D10 250ml bag; 2mg/kg.


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## TRSpeed (Sep 13, 2015)

NPO said:


> I specifically spoke to our medical director about the switch to D10 from D50, after bring it up in medic class and my instructor knowing nothing of the new trend.
> 
> He cited several reasons, including recent shortages, availability for pediatric patients (No D50 for peds), less risk of tissue necrosis, and a simpler protocol that meets all patients rather than one adult and one ped, in addition to the known benefit of not spiking BGL.
> 
> Our current protocol is D10 250ml bag; 2mg/kg.


5ml/Kg


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## Tigger (Sep 13, 2015)

I do not understand why we use measurents of volume in medication administration protocols. Clearly things come in different concentrations and the protocol should not have to account for all that.


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## chaz90 (Sep 13, 2015)

Tigger said:


> I do not understand why we use measurents of volume in medication administration protocols. Clearly things come in different concentrations and the protocol should not have to account for all that.


Absolutely. Effective "units" of any medication aren't determined by their volume, so I don't see why a protocol should ever even mention it.


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## NomadicMedic (Sep 13, 2015)

So, how do we measure a fluid bolus?


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## Tigger (Sep 13, 2015)

Fair enough. But for the most part, it doesn't seem to be the proper measurement. Our racemic epi is done in volume as well, which makes no sense.


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## DesertMedic66 (Sep 13, 2015)

If your company only buys 1 brand of medication and is only 1 concentration where is the issue?

Our protocols list the dose and volume for every single medication


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## Tigger (Sep 13, 2015)

DesertMedic66 said:


> If your company only buys 1 brand of medication and is only 1 concentration where is the issue?
> 
> Our protocols list the dose and volume for every single medication


Medication shortages happen. Sometimes it's practical to carry different concentrations of the same medication (we are doing this with Ketamine). Even my very large AMR operation struggles to keep the same concentrations on the ambulances (and we stock all the fire departments, making us the largest combined EMS service in Colorado). 

It's also the technician mindset. Joe mouthbreather medic just knows that he needs to give Xml of medication, but he doesn't actually know how to calculate the actual amount of medication he is giving.


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## NomadicMedic (Sep 13, 2015)

Tigger said:


> Medication shortages happen. Sometimes it's practical to carry different concentrations of the same medication (we are doing this with Ketamine). Even my very large AMR operation struggles to keep the same concentrations on the ambulances (and we stock all the fire departments, making us the largest combined EMS service in Colorado).
> 
> It's also the technician mindset. Joe mouthbreather medic just knows that he needs to give Xml of medication, but he doesn't actually know how to calculate the actual amount of medication he is giving.




One tan box, one purple box.


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## Carlos Danger (Sep 13, 2015)

Tigger said:


> Medication shortages happen. Sometimes it's practical to carry different concentrations of the same medication (we are doing this with Ketamine). Even my very large AMR operation struggles to keep the same concentrations on the ambulances (and we stock all the fire departments, making us the largest combined EMS service in Colorado).
> 
> It's also the technician mindset. Joe mouthbreather medic just knows that he needs to give Xml of medication, but he doesn't actually know how to calculate the actual amount of medication he is giving.



Dosing by volume is entirely legitimate.

Obviously, one still needs to know the mg/kg dose, and adjustments need to be made for non-standard concentrations. 

But assuming the concentration is usually the same, writing protocols based on a standard concentration makes perfect sense. It skips an entire med calc step where mistakes can be made.

It is actually the opposite of a technician mindset. It is efficient because concentrations don't vary that much, yet when they do, adjustments are made.


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## Tigger (Sep 13, 2015)

Remi said:


> Dosing by volume is entirely legitimate.
> 
> Obviously, one still needs to know the mg/kg dose, and adjustments need to be made for non-standard concentrations.
> 
> ...


Which is simply not a luxury many agencies have. Mistakes can be made in calculation, and mistakes can be made when providers lapse into habit and assume that all medications are packaged the same. A good provider should not do that, just as a good provider should be able to do some simple med math calculations. It does not make sense to have a protocol for every medication concentration, as that is not a known quantity.


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## Carlos Danger (Sep 13, 2015)

Tigger said:


> *Which is simply not a luxury many agencies have*. Mistakes can be made in calculation, and mistakes can be made when providers lapse into habit and assume that all medications are packaged the same. A good provider should not do that, just as a good provider should be able to do some simple med math calculations. It does not make sense to have a protocol for every medication concentration, as that is not a known quantity.



Are there really that many concentrations out there for the drugs that are commonly administered by paramedics?

Is a typical paramedic realistically going to encounter more than 1 or 2 concentrations of their most commonly administered drugs? 

Call me a technician, I suppose.


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## Tigger (Sep 13, 2015)

Remi said:


> Are there really that many concentrations out there for the drugs that are commonly administered by paramedics?
> 
> Is a typical paramedic realistically going to encounter more than 1 or 2 concentrations of their most commonly administered drugs?
> 
> Call me a technician, I suppose.


I'm not calling you anything, just pointing out that there are many providers who have no idea what exactly they are giving when they push the plunger. I guess I don't see it as an unrealistic expectation to have to do simple math. 

We have changed concentrations for mag (four times), vec, succs (I think), dextrose, versed, morphine, fentanyl, ketamine, and naloxone in the last eighteen months. This is not an ideal situation, but we have been able to maintain stock on the all ambulances in a cost effective manner. But since the protocols are not written as "administer Xml," we do not have to change anything, which I guess seems sensible to me.


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