Glucagon vs IV Dextrose

[MasterIntubator]

There was a small study for rectal glucose, and the absorption rate was amazing, and better than oral and almost neck and neck with IV doses. I think it fell out of favor.... but it was interesting.

:-/

 

[usafmedic45]

Not quite sure where you are getting that from. Can you send me the specifics on that particular study? The rectal route was one of our options for administration of glucose under the "its better than nothing if you don't have immediate access to ALS and oral glucose is not an option". However, it fell out of favor because there were several studies which should poor absorption especially when the rectum was not completely devoid of feces.

Aman J, Wranne L. Treatment of hypoglycemia in diabetes: failure of absorption of glucose through rectal mucosa. Acta Paediatr Scand. 1984 Jul;73(4):560-1. No abstract available.

Attvall S, Lager I, Smith U. Rectal glucose administration cannot be used to treat hypoglycemia. Diabetes Care. 1985 Jul-Aug;8(4):412-3

There have been similar reports for diazepam and for rectal glucagon (see Parker DR, Braatvedt GD, Bargiota A, Newrick PG, Brown S, Gamble G, Corrall RJ. Glucagon is absorbed from the rectum but does not hasten recovery from hypoglycaemia in patients with type 1 diabetes. Br J Clin Pharmacol. 2008 Jul;66(1):43-9. Epub 2008 May 27.

I'm only aware of one positive study for the use of rectal dextrose in hypoglycemia and it was a pilot study in rats:
McGee D, Chen A, de Garavilla L. Dextrose is absorbed by rectum in hypoglycemic rats. J Emerg Med. 2003 Apr;24(3):253-7.

I beleive Glucagon is also a little harder on the body and does not last as long. Especially in seniors.

It's not particularly long lasting but then again neither is D50 (or a lot of the drugs we use). As for "harder on the body", I don't really think that is much of a concern for the most part since hypoglycemia is pretty brutal in and of itself. Short of hypoxia, it's one of the faster ways to kill or gork someone by derailing of their basic bodily functions.

 

[Akulahawk]

Personally, I prefer the D50. You'll never see me shove it in fast. One, it's pretty thick stuff... two, give it slowly and it'll have a chance to become a bit more diluted so it won't be like syrup coursing through someone's veins...

If I could give 25mg Dextrose in a D10 concentration... that would certainly keep tissue necrosis possibilities down to a minimum if it extravasates. Unfortunately, we didn't carry 250mL bags... so I just did D50 slow IVP. Works pretty well, actually.

 

[JPINFV]

Glucagon should be considered first then IV glucose second if glucagon does not work or should be considered first if glucagon is unlikely to work.

Why go for a more invasive procedure than required and as soon as you stick a drip into somebody they must be transported, so why not give them some glucagon and leave em at home?

I think that sticking a needle into a muscle and sticking a needle inside a tube into a vein is pretty much equal in the invasiveness part.

Also, why would anyone have to transport just because they started an IV? D/Cing an IV isn't exactly rocket surgery.

Also, why go for Glucagon OR D50 over D10 or D25 in a simple diabetic? Lower concentrations of dextrose don't overshoot as much AND, unlike Glucagon, doesn't destroy any reserves the patient has.

 

[usafmedic45]

I think that sticking a needle into a muscle and sticking a needle inside a tube into a vein is pretty much equal in the invasiveness part.

Also, why would anyone have to transport just because they started an IV? D/Cing an IV isn't exactly rocket surgery.

Also, why go for Glucagon OR D50 over D10 or D25 in a simple diabetic? Lower concentrations of dextrose don't overshoot as much AND, unlike Glucagon, doesn't destroy any reserves the patient has.

You do have a very good point about the reserves issue.

 

[the_negro_puppy]

Glucagon should be considered first then IV glucose second if glucagon does not work or should be considered first if glucagon is unlikely to work.

Why go for a more invasive procedure than required and as soon as you stick a drip into somebody they must be transported, so why not give them some glucagon and leave em at home?

I understand the logic but our protocols state:


"Glucose 10% is the preferred treatment for hypoglycaemia patients unable to take oral glucose. This is due to its rapid onset and ability to restore blood glucose concentration to normal values"

The reference provided with this was:

Collier, A, Steedman, D, Patrick A, et al. 'Comparison of intravenous glucagon and dextrose in treatment of severe hypoglycaemia in an accident and emergency department'. Diabetes Care 1987;10: 712-5

One of our instructors justified this by stating that when he uses 10% glucose for a hypo, he know its going to work and quickly (1-3 mins onset) however this is not the same with glucagon due to depletes glycogen stores and other factors (4-7 minute onset)

Our dosages are 150ml followed by 100ml boluses while BGL < 4.0mmol

no max dose

Paediatric 2.5ml per kg


Also we do not have to transport once IV has been put in- we are permitted to remove IV and apply dressing/band-aid etc to site.

 

[18G]

Our protocols state to give 1 amp of D50 for hypoglycemia. I personally push it and wait for pt. response... usually pt. responds great and can stop at half an amp. I agree with not overshooting the BG level. The goal should be to return the pt. to being euglycemic with a substantial high carb meal to maintain that level versus making the pt. hyperglycemic.

I didn't see it mentioned anywhere here but there is also a role for glucagon in treating anaphylaxis that is refractory to epinephrine.

 

[Melclin]

Thankfully we don't have any of that "If an IV has been started, they must be sick enough to go to hospital" crap.

Protocol aside, I don't know that I like the idea of chosing one drug over another based on the the idea that it means you can leave them at home.

Glucagon can take a long time to work, if it works at all. During which time they continue to be hypoglycaemic. I would be uncomfortable spending all that time buggerising around glucagon when there is a better option sitting right next to it in my drug bag.

The IV=transport thing really needs addressing. Is it an actual policy that you would get in trouble for breaking, or is it just part of the culture?

 

[MrBrown]

Our guidelines state any significant intervention requires transport- defined as a medicine or IV fuid except where exceptions exist for hypos, seizures, palliative care and where the AOs believe transport is not required.

Now in practice Brown has never given anybody IV glucose and left them at home, and removing an IV is not rocket science. However its a grey area that Brown should follow up.

 

[MasterIntubator]

Not quite sure where you are getting that from.

Round table discussion back in the early 90's with a bunch of medical nerds and an article in hand in the pediatric ICU ward

Can you send me the specifics on that particular study?
Nope.... but I am sure somewhere out in google-land, its out there.

You have already done some homework.... and I have not. Has not greatly interested me lately about it... it was just an interesting thought I had back in my head of potentially tried and failed things related to the topic.
I do appreciate the update, because I really never looked further into it. We kinda sat around the table back then and leaned back saying, "Not me... ""

 

[rhan101277]

Thankfully we don't have any of that "If an IV has been started, they must be sick enough to go to hospital" crap.

Protocol aside, I don't know that I like the idea of chosing one drug over another based on the the idea that it means you can leave them at home.

Glucagon can take a long time to work, if it works at all. During which time they continue to be hypoglycaemic. I would be uncomfortable spending all that time buggerising around glucagon when there is a better option sitting right next to it in my drug bag.

The IV=transport thing really needs addressing. Is it an actual policy that you would get in trouble for breaking, or is it just part of the culture?

Yeah but I could not obtain IV access. So I used glucagon and it did work after about 10 minutes. Pt was still conversing just confused.

 

[Aidey]

I couldn't get an IV last night on a diabetic pt. tried 3x and then resorted to IM glucagon. Pt had a CBG of 51 but was conversing, slow to respond and somewhat confused. Ten minutes after administration CBG increased to 78.

I had another one that I did get an IV on and they got a AMP of D50 and then a D5W drip TKO.

Yeah but I could not obtain IV access. So I used glucagon and it did work after about 10 minutes. Pt was still conversing just confused.

Why didn't you use oral glucose?

 

[rhan101277]

Why didn't you use oral glucose?

He would converse and be confused and then not respond and then back to responding so I did not give it.

 

[Sam Adams]

I didn't see it mentioned anywhere here but there is also a role for glucagon in treating anaphylaxis that is refractory to epinephrine.

Are you referring to those pt's on BB's? I've asked a few people about it and all I got in response was blank stares and blinking...

 

[NomadicMedic]

Glucagon for refractory anaphylaxis used to be in the Thurston County Washington protocols, but I believe it was just removed (along with beta blockers) in the last revision.

Interesting article about the alternative uses of glucagon here: http://paramedicine101.blogspot.com/2010/02/common-and-uncommon-usages-of-glucagon.html

 

[clibb]

Yeah but I could not obtain IV access. So I used glucagon and it did work after about 10 minutes. Pt was still conversing just confused.

Just confused? So he could still swallow and you decide to start an IV with a BGL of 51... Neglect is my opinion.

 

[reaper]

Just confused? So he could still swallow and you decide to start an IV with a BGL of 51... Neglect is my opinion.

How in anyway is this even close to neglect?

He was the medic on scene. If he felt the Pt was not alert enough to protect airway, then he did exactly what needed to be done. He could have spent 10 minutes looking for an IV, while the brain cells cooked. No, he choose to give him Glucagon right away, so it could take effect.

That is thinking far enough ahead, to help the Pt.

 

[Aidey]

I wouldn't call it neglect, but if a patient can talk, they can swallow.

 

[JPINFV]

I wouldn't call it neglect, but if a patient can talk, they can swallow.

[not.sure.if.serious.jpg]

I have 1 word for you, just one word. Dysphagia.

 

[usafmedic45]

[not.sure.if.serious.jpg]

I have 1 word for you, just one word. Dysphagia.

Damn it JP. Why do you have to post before I do... LOL