# D50 Orally



## Grym Reaper (Apr 16, 2009)

I need some info on giving D50 orally.  I have given it orally mixed with water and ice cubes to patients in the past without any negative side effects.  I have asked a pharmacist student and a pharmacist as to any complications and they could not provide any info.  I also called my state Poison Control center and he just laughed and said its nothing worse then sugar water.


I am well aware that it is a hypertonic solution and will cause tissue necrosis intravenously if not in the vein.  What I am seeking is the possible side effects of giving it orally after dilution.  I have done this numerous times to a stable, conscious patient with no negative side effects.  This time our QA officer noticed I gave it orally, which isnt in our protocols, and advised my supervisor to talk with me about it. Long story short, it snowballed into  our State EMS director along with our State QA officer and our local EMS director getting notified along with my local QA director.  Now I have to go before the Medical Advisory Board to explain my actions.



Just a little info on the patient she is a non compliant diabetic who has called EMS over 10 times in the past 3 months and has refused transport each time.


TIA for any info.


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## maxwell (Apr 16, 2009)

Nothing wrong with PO D50.  Hell, I dont even dilute it.  Or you can give PO glucose.  Or give them OJ.  If they're cute, ask 'em out for a drink.  Yeah, its hypertonic.  But nothing wrong with that.  Its a hell of a lot gentler than drinking coke!


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## silver (Apr 16, 2009)

Was there a reason why glucose tubes weren't used?
That would be the most logical thing to give if there were alert and you didn't want to give it via IV.
So if you mix more with water, it is just drinking glucose in water. However absorption rate, time, and amount can not be controlled like sublingual tubes and IV D50. Which may possibly cause a problem, but not likely.

Of course though, I'm not experienced with this.


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## Juxel (Apr 16, 2009)

I give it PO quite frequently much to my employer's dismay.  I'm not sure how familiar all of you are with billing, but you know that treating and releasing a diabetic is quite common place.

IV + D50 gets pt a bill around $500.
D50 PO gets pt a bill around $200.

This is significant for older adults as if they do not go to the hospital medicare WILL NOT cover the bill.  Ideally, I would like to pour them a glass of OJ and make them a peanut butter sandwich, but that'll get me in hot water as our standing orders say they must be given D50 if their sugar is low.  If the pt is confused, but capable of pouring their own OJ, I let them.

Now, make sure you have a patient you are willing to sit with for a while.  PO is no where near as fast as the IV route.  You can be sitting there for 30-45 minutes before their sugar check comes back high enough to sign them.


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## Ridryder911 (Apr 16, 2009)

Do you have specific protocols to give D50w p.o.? If not then you have broken them. I have fired a Paramedic for doing such. There is no reason to give D50w p.o., if they are where they can eat then give them some carbs and protein. Ever heard of oral glucose, that is a hell of lot cheaper than giving D50w as well and is made to be administered p.o. Get in hot water for p.o. foods?

I am familar with Medicare, and NO they do not pay the same if the D50w was administered p.o. rather than I.V. As it falls into the same class of I.M.'s and other p.o. med.'s such as ASA. The ALS I charge is the IV therapy and no D50w is NOT a medication; rather a solution. Yeah, there is a difference. 

R/r 911


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## Juxel (Apr 16, 2009)

Our protocols actually read: "If conscious, consider administration of 50 ml of D50W orally or 80 gm of an oral glucose solution."  Then it goes on to say "If patient unable to take oral fluids due to altered level of consciousness consider:"

We don't carry oral glucose solution, but some of the first responder agencies who work under our medical director do (don't ask me why).  So, by our protocol, you could argue that you HAVE to give it orally if the patient is capable of taking it that way.


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## Tincanfireman (Apr 16, 2009)

Grym Reaper said:


> I gave it orally, which isnt in our protocols



Grym, I'd have to agree that administration of D50 without a standing protocol for p.o. was wrong. It's immaterial that you have done it before and not caught the eye of your QA person, but I'm thinking a quick call to your med control or getting a doc to the radio would have saved you a lot of grief.


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## jedirye (Apr 16, 2009)

Hmmm... I have contemplated getting orders for giving D50 rectally, never considered PO though. I guess if they were conscious enough to take D50 orally, they could take oral glucose as well.


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## Street Doc (Apr 16, 2009)

A little off topic but in my paramedic class and very smart medic said he has given D50 rectally (if no IV access and pt - gag reflex) numerous times.  Also, can anyone give D50 IO?


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## Ridryder911 (Apr 16, 2009)

Street Doc said:


> A little off topic but in my paramedic class and very smart medic said he has given D50 rectally (if no IV access and pt - gag reflex) numerous times.  Also, can anyone give D50 IO?



Yes, I/O as all prehospital medications can be given I/O as well as blood. 

R/r 911


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## TransportJockey (Apr 16, 2009)

Juxel said:


> Our protocols actually read: "If conscious, consider administration of 50 ml of D50W orally or 80 gm of an oral glucose solution."  Then it goes on to say "If patient unable to take oral fluids due to altered level of consciousness consider:"
> 
> We don't carry oral glucose solution, but some of the first responder agencies who work under our medical director do (don't ask me why).  So, by our protocol, you could argue that you HAVE to give it orally if the patient is capable of taking it that way.



I thought if it said consider, it wasn't a hard line 'you have to do this'


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## TransportJockey (Apr 16, 2009)

Ridryder911 said:


> Yes, I/O as all prehospital medications can be given I/O as well as blood.
> 
> R/r 911



How hard would it be to push D50 I/O? I've been told that it's harder to push NS through it, let alone something that thick. I've never had the chance to actually use an I/O, so that's why I'm asking


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## Juxel (Apr 16, 2009)

jtpaintball70 said:


> I thought if it said consider, it wasn't a hard line 'you have to do this'



You are right.  I guess I didn't explain what I meant well.  I was trying to say that if you have a patient who is conscious (as documented by your initial assessment on the PCR) yet you administered the D50W IV, you could, in theory, be reprimanded for that as our protocols don't allow you to "consider" the IV route until the patient is "unable to take oral fluids due to altered level of consciousness".

If my patient is conscious and capable of pouring his own OJ and making a peanut butter sandwich, I do everything I can to allow him to do so.  If my patient is conscious but not capable of doing that, I have him drink the D50W.


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## Ridryder911 (Apr 16, 2009)

jtpaintball70 said:


> How hard would it be to push D50 I/O? I've been told that it's harder to push NS through it, let alone something that thick. I've never had the chance to actually use an I/O, so that's why I'm asking



I have always used pressure infuser bags or a blood pressure cuff on the bag for infusions of a I/O. Yes, one has to administer much slower, as well as most other med's. 

I always push D50w slow; no matter what the site, gauge of catheter, etc.. in fact; I no longer administer D50w if I can avoid it. Scientific studies have proven D10w or diluted D50w or even 12.5 grams of D50w diluted out will produce the same effects without the side effects such as rebound glucose, headaches, chills and tissue necrosis.. 


R/r 911


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## Juxel (Apr 16, 2009)

jtpaintball70 said:


> How hard would it be to push D50 I/O? I've been told that it's harder to push NS through it, let alone something that thick. I've never had the chance to actually use an I/O, so that's why I'm asking



If you hook your NS up to a pressure bag it flows very well.  Be careful with a conscious patient though as (at least in my experience) the insertion seems to be no more painful than an IV, but the administration of fluid is extremely painful.  I always give 1mg/kg of lidocaine (up to 50mg) before any fluid or other medications which seems to make it relatively comfortable.


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## Sasha (Apr 16, 2009)

jtpaintball70 said:


> How hard would it be to push D50 I/O? I've been told that it's harder to push NS through it, let alone something that thick. I've never had the chance to actually use an I/O, so that's why I'm asking



While we are on the subject of D50 IO, I know this has probably be answered before but I can't find/remember it... Why isn't D50 necrotic to the bone like it would be to an unpatent IV site?


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## Ridryder911 (Apr 16, 2009)

Sasha said:


> While we are on the subject of D50 IO, I know this has probably be answered before but I can't find/remember it... Why isn't D50 necrotic to the bone like it would be to an unpatent IV site?



Because it is the "tissue" sensitivity and the hypertonicity of the concentrate causing the skin tissue (cells) to actually cause severe damage enough to cause necrosis in some patients. The injection into an I/O is into the bone marrow = blood stream. The periosteum of the bone is calcified. 

R/r 911


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## AnthonyM83 (Apr 17, 2009)

Street Doc said:


> A little off topic but in my paramedic class and very smart medic said he has given D50 rectally (if no IV access and pt - gag reflex) numerous times.  Also, can anyone give D50 IO?



I would imagine that such a permeable area might allow some damage to occur because of the hypertonicity of the D50? Just seems dangerous since it's not contained within a blood vessel. Walls of colon/rectum absorb it, but then what? Not 100% of it can possibly go into the blood stream. What happens to the rest? 

In the end, I don't know the answer. Those would just be my concerns.


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## Ridryder911 (Apr 17, 2009)

Personally, I do not understand why one would want to administer medications inappropriately? Why give D50w orally when there is oral glucose for a 1/4 of the price or even having a protocol for allowing such? Why administer D50w rectally when one can administer Glucagon? 

If your protocols are not sufficient, can you not make suggestions to your medical director on the inadequacies? Maybe new or revised protocols? Would we allow a continuation of non current medical therapy for cardiac care? 

As a diabetic, I personally would not want to have to drink D50w when a slice of pizza would definitely be in my best interest and taste and personally would not like to have my rectal vault necrosing and rotting out. 

R/r 911


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## Street Doc (Apr 17, 2009)

Ridryder911 said:


> personally would not like to have my rectal vault necrosing and rotting out



So I take it that rectal D50 is not a good idea.  

What would you do for hypoglycemia with no IV access and no glucagon in your box (only med for low BGL is D50 in Southeast Michigan)?  IO or rapid transport?  Hospital is usually 10 to 15min away at most for me.  
What bodily harm can occur from not correcting hypoglycemia in a timely manor?


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## bonedog (Apr 17, 2009)

As we don't charge by the Rx, I have trouble understanding why one would be fired for an action such as this. Oral glucose is definitely more appropriate, however, here we encouraged to think outside of the box and if someone can defend their treatment plan more power to them.(This is part of our training program where students have to give a capstone defence for one of their complexed calls in front of a panel of three docs and three mentor/preceptors)
Also our protocols are considered guidelines, we rarely call for medical direction and it is almost exclusively at the discretion of the medic.


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## Ridryder911 (Apr 17, 2009)

bonedog said:


> As we don't charge by the Rx, I have trouble understanding why one would be fired for an action such as this. Oral glucose is definitely more appropriate, however, here we encouraged to think outside of the box and if someone can defend their treatment plan more power to them.(This is part of our training program where students have to give a capstone defence for one of their complexed calls in front of a panel of three docs and three mentor/preceptors)
> Also our protocols are considered guidelines, we rarely call for medical direction and it is almost exclusively at the discretion of the medic.



The reason was simple, we did not have standing orders for p.o. D50w and why administer if the LOC has the ability of swallowing why administer it that way?  They were at the scene in the patients house with protein/carbohydrate food; which is much better than rebounding glucose. Also, we carry oral glucose as well that was not administered. Short and simple, improper tx was administered. 

Yes, we have the same philosophy but part of the critical thinking is to think about the whole picture. The same would be true in administration of Lasix, etc. Would you give it p.o. as well if you did not start an I.V.? 


R/r 911


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## bonedog (Apr 17, 2009)

R/r911,if the patient was at risk for iatrogenic aspiration then termination would be the appropriate course of action. This couldnot be considered critical thinking.

If a patient was unconscious IV is the preferred course of administration to limit cerebral damage. I usually only use D50W in cardiac arrest as you get the same effects with D10W without the sclerosis.

Don't use lasix much anymore, CPAP and NTG. Sometimes for renal failure. Cann't say I have ever given it PO though.


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## ResTech (Apr 18, 2009)

I personally would not be in favor of giving D50 PO as there are better options for increasing BG level. In Maryland, we have the option of using Glucagon and also IO. If they are conscious enough to swallow I would not even be thinking to give the pt. D50 PO. Concentrated OJ and food along with oral glucose works quite well. 

As far as the firing thing goes... I'm a very liberal person and would never fire anyone except as a last resort once all forms of discipline have been implemented. Discipline is not to punish but to serve as a corrective and remedial action. If a provider does something like give D50 PO and no harm was done... why fire them? Explain that its not acceptable practice at your agency and leave it at that.


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## MSDeltaFlt (Apr 18, 2009)

Ridryder911 said:


> Personally, I do not understand why one would want to administer medications inappropriately? Why give D50w orally when there is oral glucose for a 1/4 of the price or even having a protocol for allowing such? Why administer D50w rectally when one can administer Glucagon?
> 
> If your protocols are not sufficient, can you not make suggestions to your medical director on the inadequacies? Maybe new or revised protocols? Would we allow a continuation of non current medical therapy for cardiac care?
> 
> ...


 
True, Rid.  I have tasted D50.  Cracked a joke to a doctor once while he had it in his hand.  He skeeted it across the room and caught my mouth.  Tasted like 100+ wedding cakes on one spoon on my tongue.  D*mn, that is *rrriiiccchhh!*

And a "rotting rectal vault"?!?  That would have to be a real pain in the arse.

Sorry.  The shot was there.  I had to take it. ^_^


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## Markhk (Apr 18, 2009)

I've given D50 IO (after multiple failed IV attempts, BSL 30 mg/dL). For my patient it was quite a difficult medication to push -- requires a lot of force even if you're trying to do it slowly. I was worried that I might extravasate considering how hard I was pushing. 

It was pretty amazing though. I barely got 5 grams into the pre-load when the patient started turning around...wanting to yank the IO out. 

Patient came into the ED several weeks later for another episode of hypoglycemia, and apparently was telling the medics (of another department), "Last time this happened the paramedics tried to kill me putting a needle in my bone!". She got out of the ambulance, saw my crew sitting around and promptly started screaming.


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## jedirye (Apr 19, 2009)

There was already a thread discussing rectal D50: Here

It is quite informative.


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## ffmedic08 (Apr 19, 2009)

Everything is always situational, and no one can really accurately say...


In my experience, I dont know if it was a lack of creativity or what but I've never heard of D50 orally... interesting though. Thats one of those lil tid-bits you put in the back of your 'filing cabinet' for when you are on that once-in-a-lifetime call and NOTHING is goign correctly.... get what I'm saying???


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