After all, top priority is to reverse hypoglycemia as fast as possible. But in the midst of stabilizing the patient, how often do we consider the potential aftermath of concentrated glucose? After administration of D50 there is an excess amount of glucose available, leading to increased uptake and utilization by the tissues, which suppresses both gluconeogenesis and glycogenolysis.
Without continued administration of dextrose-containing fluids, this may result in rebound hypoglycemia. Unfortunately, the prevalence of rebound hypoglycemia from D50 is not well documented. It is well known that intravenous administration of hypertonic fluids may result in harm to surrounding tissues. In fact, the osmolarity of D50 is even greater than that of 8. One small randomized controlled trial evaluated the effectiveness of D10 vs D50 for the treatment of hypoglycemia by EMS providers in the pre-hospital setting.
The investigators pushed small 5 g aliquots of each 50 mL of D10 and 10 mL of D50 , while waiting one minute in between doses to reassess the patient. The maximum cumulative dose of dextrose permitted was 25 g. This drug can be used for a variety of medication extravasations including: calcium, total parenteral nutrition, many antibiotics, potassium salts, vinca alkaloids, sodium bicarbonate, and mannitol. It is most effective if administered within two hours of extravasation in a concentration of 15 units per mL, with 0.
There may be some benefit to injecting a portion of the hyaluronidase through the IV catheter, if it has not been removed already. In Falkowski v. Maurus, 26 the plaintiff was a diabetic who suffered an acute episode of hypoglycemia.
The patient soon complained of pain in his hand, where the IV was placed. Shortly thereafter, the paramedic removed the IV. Subsequent examination revealed that the plaintiff had suffered a complete distal ulnar nerve palsy. Under Louisiana law, a paramedic is liable only for acts that are intentional or grossly negligent. The plaintiff sued the paramedics, alleging gross negligence in the administration and supervision of the intravenous D50 bolus.
The trial court found for the paramedics, and the plaintiff appealed. The appellate court affirmed the lower court decision based upon several points. The appellate court ruled that the paramedics clearly had not engaged in grossly negligent behavior.
It is interesting to note that the plaintiff in this case was morbidly obese, weighing pounds, which may have made swelling of the IV site more difficult to notice by the paramedics. Case discussion: This case reflects the need to educate pre-hospital personnel about the risk of IV extravasation and the recognition of its signs and symptoms. The paramedics in this case rendered therapy that was within the standard of care. The care was not in any way grossly negligent, the standard under Louisiana law for holding a paramedic liable.
Other cases support the position that simply because an extravasation injury has occurred, negligence cannot necessarily be presumed. As in all professional malpractice cases, the plaintiff must prove all four elements of the case: duty, a breach of the standard of care, proximate causation, and damages. An adverse outcome alone is not sufficient to establish that a physician or other health care provider was negligent.
Review and pathophysiology: Dextrose solutions, like many other crystalloid fluids, are mildly acidic with a pH of 3. This results in intracellular dehydration and cellular death. The acidic nature of the dextrose solution also causes intracellular proteins to precipitate, leading to cell death and skin necrosis.
Mechanical compression also may occur during a large dextrose extravasation and cause a pressure necrosis of tissues. Signs and symptoms of dextrose extravasation are similar to injuries from other IV solution extravasations. Large bullae may appear within a few hours of extravasation, along with warmth, edema, erythema, and erosions.
The extent of the injury with dextrose solutions depends on the volume, composition, location, time period before the infiltration is discovered, and the treatment measures implemented after extravasation.
Recommendations: Conservative management is the treatment of choice for dextrose extravasation injuries. Recommendations include a loose dressing, elevation of the extremity, and cold packs to the area. It also is advised to avoid warm soaks or compresses, as this may contribute to skin maceration. To reduce the risk of infiltration and extravasation, infuse dextrose solutions, like all hyperosmolar solutions, into a large vein using a flexible larger bore catheter.
Stop the infusion at the first sign or symptom of an extravasation, and aspirate any remaining fluid within the IV tubing. There is limited evidence regarding the efficacy of hyaluronidase in dextrose extravasation injuries. As early as , cases of calcium chloride solution extravasation injuries were reported.
In Riley v. United States , 37 the plaintiff suffered tissue necrosis of the forearm and hand near the site of an IV. In this case, the patient had a history of severe regional ileitis requiring a total colectomy and ileostomy at age 28, and she suffered from chronic hypocalcemia due to malabsorption. She presented to the ED with tetany in her arms and legs and was given IV as well as oral calcium replacement.
Two days after admission, another physician noted erythema and impending necrosis of the right forearm and left hand where the calcium had been infused. The patient required two small skin grafts on her right forearm and left hand. She had no residual functional damages; however, there was obvious discoloration and scars around the grafted skin.
The court ruled in favor of the defendant and emphasized that undesirable results stemming from a medical procedure are not, by themselves, conclusive proof of negligence. In the similar but more recent case, Odak v. The plaintiff sued for damages. The procedural rules provided that, in medical malpractice cases, the plaintiff must certify that an expert has given the plaintiff a written report as to the negligence of the medical provider and posted a bond prior to trial.
The plaintiff failed to comply with these requirements. The plaintiff argued that this case was a res ipsa loquitor case and, therefore, no expert testimony was needed. In such cases e. The precise procedural effect of the doctrine is beyond the scope of this article. The plaintiff argued that persons do not suffer such burns in a hospital nursery absent negligence. The court disagreed and stated that this was not a res ipsa loquitor case.
The court further stated that there was an issue as to whether the infusion had caused the injury. Case discussion: These cases have medical-legal significance as a general proposition in that these courts did not allow application of the res ipsa loquitor doctrine in this circumstance, and required expert testimony that the standard of care was breached.
The majority of courts agree that application of the res ipsa loquitor doctrine in these cases extravasation is inappropriate and, in addition, that expert witness testimony is required as to the standard of care. The majority of extravasation injury cases do not reflect malpractice, but rather an unavoidable adverse outcome of medication infusion. ED physicians and nurses still need to be able to identify extravasation injuries and treat them promptly when injury occurs.
Early recognition and treatment will build a strong defense for the practitioner if an allegation of malpractice arises.
At least one court has disagreed in extravasation injury cases. It argued that laypersons would know that such injuries do not occur absent negligence. The court stated that the layperson has this knowledge from the common experience of receiving shots with needles. This case does contain a vigorous dissent in which it was argued that the res ipsa loquitor doctrine was allowed far too frequently whenever a medical procedure is performed and an unsatisfactory result occurred.
The dissent argued that a layperson could hardly be expected to know that a medication will burn surrounding tissue if it escapes the vein. Calcium gluconate and calcium chloride are weak acidic hypertonic solutions, and it is because of this characteristic that they are capable of precipitating protein, which produces cell death and skin necrosis.
Calcification has been attributed to massive collagen degeneration, soft-tissue necrosis, or an increase in mast cell production. The lesions appear as brown to white papules or nodules and may be associated with warmth, fluctuance, or even skin necrosis. Radiographic studies can demonstrate soft-tissue calcification.
Most patients with a calcium extravasation injury experience a burning sensation upon infiltration. Mild erythema and induration usually appear after three days. A variety of treatment options for calcium extravasation injury have been recommended.
Most therapeutic regimens include elevation and cold compression for the edema. Recommendations: Recommendations to help avoid a calcium solution extravasation injury include using a stable and secure IV site, utilizing a flexible IV catheter rather than a needle, and a slow infusion of any calcium bolus. Inspection with diligence of IV sites during calcium infusion therapy may identify an IV infiltration before a significant amount of the solution extravasates.
Except in rare emergency situations, small-caliber IV catheters placed in tenuous locations, such as the dorsum of the hand, are not appropriate for this irritating solution. Often, a calcium chloride bolus or infusion can be substituted with one or more calcium gluconate boluses or infusions. As 10 cc of calcium gluconate contains one-third the elemental calcium of a similar volume of calcium chloride, an extravasation will be less damaging, as local tissue damage directly correlates with the amount of free calcium ion present in the offending solution that extravasates.
The rate of infusion for a direct undiluted IV bolus is 0. Once a calcium extravasation is identified, stop the infused solution and aspirate the catheter. Reference an established extravasation protocol immediately. See Table 1. Elevate the extremity and place a cold pack onto the area.
Inject hyaluronidase into the subcutaneous tissues surrounding the extravasation in five separate areas 15 units diluted in 1 mL of NS, with 0. Some improvement in calcinosis cutis has been noted in an animal model with subcutaneous injection of triamcinolone acetonide; however, further investigation in humans is required before this can be supported as a standard of care. Calcium extravasations will require close clinical follow-up to assess for signs of skin necrosis or complications.
Because of the lack of efficacy and these risks, calcium is no longer indicated during during resuscitations and should be used only for suspected hypocalcemia, hyperkalemia, and calcium-channel blocker overdose. Early tissue debridement of the extravasated soft tissue does not seem to improve cosmetic outcome, but any tissue necrosis that subsequently appears may require surgical debridement and possible skin grafting.
In Kapadia v. Alief General Hospital , 69 a diabetic patient visited her primary care physician, who recommended inpatient treatment for stabilization of her hyperglycemia.
She refused to be admitted and left against medical advice. Three days later, she suffered several consecutive grand mal seizures at her home without regaining consciousness. The consulting neurologist prescribed 1, mg IV phenytoin as a loading dose to prevent further seizures.
The IV was stopped and moved to the right hand. Gangrene later developed that was refractory to medical treatment and ultimately required amputation of the left hand.
The nurse testified that the IV was given in 50 mg increments slowly; however, the terms "IV push" were used in the record. She stated that it took at least 30 minutes to give the medication. The family argued that they had noticed the injury occurring after minutes of infusion, and that the nurse did not respond promptly to calls for help. She had multiple attempts at IV access and eventually a 22G IV was established and D50 was infused into her right forearm. Extravasation of the dextrose was noted after approximately 12 g of the medication was infused.
She was given a dose of glucagon intramuscularly and her mental status improved. Is extravasation a malpractice? In the Medical world, occurrence of extravasation or injury thereof would not be regarded as negligence , but failure to recognize it or take remedial measures would probably be considered negligent.
Akbar Terhart Pundit. What is d50 in medicine? Hypertonic dextrose D50 is commonly administered in the ED both for the routine treatment of patients with symptomatic hypoglycemia and for the empiric treatment of patients with altered mental status. Henri Ghezzi Pundit. Which of the following is a patient related risk factor for increased tissue damage in extravasation? Berenice Chacha Pundit. Is d10w a Vesicant? Vesicants are IV solutions and medications that cause ischemia and necrosis.
Vesicants are extremely acidic or basic pH less than 5 or greater than 9 , hyperosmolar extremely concentrated , or vasoconstrictive cause the blood vessels to constrict. Many chemotherapy drugs are vesicants. Tinguaro Kappauf Pundit. What happens after infiltration? Infiltration happens when water soaks into the soil from the ground level.
It moves underground and moves between the soil and rocks. Some of the water will be soaked up by roots to help plants grow. Some of the water keeps moving down into the soil to a level that is filled with water, called ground water.
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