Dextrose 50% Tissue Necrosis??

Gomassie

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

NYMedic828

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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

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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?
 

Medic Tim

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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.
 

NYMedic828

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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

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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

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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.
 

NYMedic828

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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

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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.

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

lightsandsirens5

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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....
 

VFlutter

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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.
 

NYMedic828

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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.
 

VFlutter

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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.
 

TransportJockey

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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.
 

usalsfyre

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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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