# Dextrose 50% Tissue Necrosis??



## Gomassie (Oct 21, 2012)

We all know that d50 causes tissue necrosis if it extravasated. Why?? What is the PROCESS at work??


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## NYMedic828 (Oct 21, 2012)

Gomassie said:


> We all know that d50 causes tissue necrosis if it extravasated. Why?? What is the PROCESS at work??



I'm not 100% but I believe the cause is extreme osmolarity of a solution with a solute concentration of 500mg/ml

The massive pull that is exertered by the hypertonicty of such a concentrated substance directly in contact with cells dehydrates the cells resulting in cell death and subsequent necrosis.

Again, not 100% but I think that is it.


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## Medic Tim (Oct 21, 2012)

Gomassie said:


> We all know that d50 causes tissue necrosis if it extravasated. Why?? What is the PROCESS at work??



Are you familiar with the terms hypotonic, isotonic and hypertonic?


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## Medic Tim (Oct 21, 2012)

NYMedic828 said:


> I'm not 100% but I believe the cause is extreme osmolarity of a solution with a solute concentration of 500mg/ml
> 
> The massive pull that is exertered by the hypertonicty of such a concentrated substance directly in contact with cells dehydrates the cells resulting in cell death and subsequent necrosis.
> 
> Again, not 100% but I think that is it.



Looks like you beat me to it.


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## NYMedic828 (Oct 21, 2012)

While we are on the topic, be mindful that D50 isn't the only thing we administer capable of causing local necrosis.

Calcium for example is capable of causing massive necrosis. I've read calcium is actually capable of producing full thickness necrosis.

Even hypo/hypertonic saline can produce necrosis by overhydration/dehydration of cells.

Personally I take a lot of pride in showing up at the hospital with a clean, patent IV site. I know many guys who skip using a lock/flush and just directly attach a drip set but personally I like to always use a saline lock/flush as it provides a detachment point other than the catheter and more importantly it allows me to safely ensure my site is good to go before administering any meds. Unless you extravasate enough normal saline to substantially stretch the connective tissues of the skin you aren't going to cause any adverse effects. Better safe than sorry.


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## Gomassie (Oct 21, 2012)

That is essentially correct but what I'm looking for is deeper. Why is d50 toxic only if it extravasates? It does not harm your skin or damage the vasculature, so why should it only be toxic in the interstitial space? I can't find this anywhere. Also, yes I fully understand solution solubility.


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## Gomassie (Oct 21, 2012)

Very true nymedic828. I have researched how saline can cause necrosis. I'm just stumped on how actual d50 causes it. I'm not sure if it has to do with it being a hexose sugar. Not sure how toxic hexose sugars are on a cellular level.


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## NYMedic828 (Oct 21, 2012)

Gomassie said:


> That is essentially correct but what I'm looking for is deeper. Why is d50 toxic only if it extravasates? It does not harm your skin or damage the vasculature, so why should it only be toxic in the interstitial space? I can't find this anywhere. Also, yes I fully understand solution solubility.





Your veins and arteries are made up of 3 layers.

Tunica externa
Tunica media
Tunica intima, or Adventia.

The tunica externa is comprised of fibrous strong connective tissue which basically makes a protective sheathe for the vessel.

The tunica media is comprised of smooth muscle and more elastic connective tissues.

The tunica interna is comprised of a thinner endothelial layer. The catch here is that this endothelial layer doesn't actually allow fluid to cross. (Non permeable) the layers of a vessel actually recieves nutrients from even smaller vessels spanning their walls. Hence, the tunica intima contains the hypertonic solution in a benign manor. 

Trouble arises when these solutions reach permeable membranes such as capillaries. Thankfully, veins are post capillary circulation and the contents can be dispersed and diluted by the time they circulate to the capillaries.


I'm not 100% once again, I'm just trying to recall that chapter in my A&P book. There is a good chance what I just wrote is 90% made up and incorrect...


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## lightsandsirens5 (Oct 21, 2012)

NYMedic828 said:


> While we are on the topic, be mindful that D50 isn't the only thing we administer capable of causing local necrosis.
> 
> Calcium for example is capable of causing massive necrosis. I've read calcium is actually capable of producing full thickness necrosis.
> 
> ...



Promethazine is a problem as well, if it etxtravasates SQ, correct?


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## Medic Tim (Oct 21, 2012)

lightsandsirens5 said:


> Promethazine is a problem as well, if it etxtravasates SQ, correct?



Correct


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## usalsfyre (Oct 21, 2012)

lightsandsirens5 said:


> Promethazine is a problem as well, if it etxtravasates SQ, correct?



Promethazine is irritating to the vasculature rather than tissue. The current preferred route is deep IM.


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## VFlutter (Oct 21, 2012)

lightsandsirens5 said:


> Promethazine is a problem as well, if it etxtravasates SQ, correct?



Don't forget Dopamine


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## lightsandsirens5 (Oct 21, 2012)

usalsfyre said:


> Promethazine is irritating to the vasculature rather than tissue. The current preferred route is deep IM.



That too. I just seem to recall hearing in school it is extremely necrotic to the SQ tissue as well. Though now I can't find anything to support that....


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## usalsfyre (Oct 21, 2012)

ChaseZ33 said:


> Don't forget Dopamine



Dopamine (or any of the pressors for that matter) is the severe, localized vasoconstriction caused by it being loose in the tissue.


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## Medic Tim (Oct 21, 2012)

lightsandsirens5 said:


> That too. I just seem to recall hearing in school it is extremely necrotic to the SQ tissue as well. Though now I can't find anything to support that....



It does. I have seen some pretty nasty ones


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## VFlutter (Oct 21, 2012)

usalsfyre said:


> Dopamine (or any of the pressors for that matter) is the severe, localized vasoconstriction caused by it being loose in the tissue.



True. But hopefully dopamine is the only pressor you are trying to run through a PIV.


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## NYMedic828 (Oct 21, 2012)

ChaseZ33 said:


> True. But hopefully dopamine is the only pressor you are trying to run through a PIV.



Epi? Vasopressin?

Granted the patient should be in arrest but should they be revived and your infiltrated IV spewed 3amps of epi and 40 of vasopressin into the interstitial space I can imagine it no being pleasant later on.


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## VFlutter (Oct 21, 2012)

NYMedic828 said:


> Epi? Vasopressin?
> 
> Granted the patient should be in arrest but should they be revived and your infiltrated IV spewed 3amps of epi and 40 of vasopressin into the interstitial space I can imagine it no being pleasant later on.



True. Let me rephrase...Dopamine is the only pressor you should be running as a drip through a PIV.


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## TransportJockey (Oct 21, 2012)

ChaseZ33 said:


> True. Let me rephrase...Dopamine is the only pressor you should be running as a drip through a PIV.



Meh, I know services that carry NorEpi and run it after a code routinely. I have protocols for Epi drips BTW as well.


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## usalsfyre (Oct 21, 2012)

TransportJockey said:


> Meh, I know services that carry NorEpi and run it after a code routinely. I have protocols for Epi drips BTW as well.



Seconded. I've routinely run norepi peripherally. It's far from ideal but short term with a good IV not a huge problem.


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## 46Young (Oct 21, 2012)

NYMedic828 said:


> While we are on the topic, be mindful that D50 isn't the only thing we administer capable of causing local necrosis.
> 
> Calcium for example is capable of causing massive necrosis. I've read calcium is actually capable of producing full thickness necrosis.
> 
> ...



Funny, just today my medic partner and I were talking about old-school ALS, like D50/thiamine/narcan, 3+3 liters of saline for shock, etc, and he mentioned how we used to just run the fluid in and not do a lock. We were saying how we now use 500cc bags instead of liter bags to save some $$$ and not over-bolus someone. If you need more, just spike another 500 bag when the last one goes down below 100.

Anyway, we have protocols that allow us to dilute D50 in 250cc's of NS for the hypoclycemic pt if their vasculature appears poor. We used to do this all the time in the field, but we just wouldn't document it. The North Shore PCR Nazis would haved tripped out for sure. Same thing with the hyperglycemic pt. If we have a BGL > 400 and an ETCO2 of 25 or less, we can run NS 1000 cc's/hr. IIRC, that's 2.77 gtts/min. We used to give hyperglycemics fluid off the record back in the day as well. They're urinating a lot, and can be hyperventilating themselves into dehydration, so some saline should help for the time being.


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## usalsfyre (Oct 21, 2012)

1000/hr? I'm usually trying to get 2Ls in inside 30min.....


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## mycrofft (Oct 22, 2012)

NYMedic828 said:


> I'm not 100% but I believe the cause is extreme osmolarity of a solution with a solute concentration of 500mg/ml
> 
> The massive pull that is exertered by the hypertonicty of such a concentrated substance directly in contact with cells dehydrates the cells resulting in cell death and subsequent necrosis.
> 
> Again, not 100% but I think that is it.



Yes

And some drugs which are thought by some to be destructive to vasculature and not musculature might be surprised it is also damaging to muscle, but a pea to marble-sized calcified scar in a muscle mass is the equivalent of a pretty good case of non-infective vasculitis or ruptured vessel. Or a sclerosed nerve or patch of necrotic periosteum with attendant issues. Keep stuff where it belongs.
We had a repetitive self-destructive pt who wolud do no food and take insulin as scheduled. FIrst time, D50 straight into antecubital vein went ok, next time he needed tens of thousands of dollars in plastic surgery and rehab therapy to replace rotten bicep tissue.


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## Akulahawk (Oct 22, 2012)

46Young said:


> Funny, just today my medic partner and I were talking about old-school ALS, like D50/thiamine/narcan, 3+3 liters of saline for shock, etc, and he mentioned how we used to just run the fluid in and not do a lock. We were saying how we now use 500cc bags instead of liter bags to save some $$$ and not over-bolus someone. If you need more, just spike another 500 bag when the last one goes down below 100.
> 
> Anyway, we have protocols that allow us to dilute D50 in 250cc's of NS for the hypoclycemic pt if their vasculature appears poor. We used to do this all the time in the field, but we just wouldn't document it. The North Shore PCR Nazis would haved tripped out for sure. Same thing with the hyperglycemic pt.* If we have a BGL > 400 and an ETCO2 of 25 or less, we can run NS 1000 cc's/hr. IIRC, that's 2.77 gtts/min.* We used to give hyperglycemics fluid off the record back in the day as well. They're urinating a lot, and can be hyperventilating themselves into dehydration, so some saline should help for the time being.


If I saw that a hyperglycemic patient was dehydrated... I'd put in as large a bore line as I can get, ensure it was patent and let it run wide open. I'd just keep a really close eye on the patient while doing that. Putting a 2nd liter bag on might be looked at pretty closely though... at least out here because we have so many hospitals so relatively close to pretty much anywhere in the County.


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## Christopher (Oct 24, 2012)

NYMedic828 said:


> Calcium for example is capable of causing massive necrosis. I've read calcium is actually capable of producing full thickness necrosis.



Calcium chloride causes tissue necrosis. Calcium gluconate does not and can be injected SQ for hydroflouric acid burns.


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## mycrofft (Oct 24, 2012)

Christopher said:


> Calcium chloride causes tissue necrosis. Calcium gluconate does not and can be injected SQ for hydroflouric acid burns.



Calcium gluconate also used to be used SQ for black widow spider bites with system symptoms.
Calcium chloride gives the puckery "bite" to some dill pickels.


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