Dextrose 50% Tissue Necrosis??

[46Young]

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.

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.

 

[usalsfyre]

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

 

[mycrofft]

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.

 

[Akulahawk]

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.

 

[Christopher]

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.

 

[mycrofft]

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.