D50 for blood glucose protocol vs juice/snacks, your thoughts

[Billy_Ruben]

I had a pt, who I had taken care of for a few days and was familiar with, that had a low blood sugar when I was coming onto my shift. His reading was 63 and he has a habit of getting low but being asymptomatic. Apparently, the day shift nurse had the same level of concern (not hugely worried) that I had. She was pretty much monitoring and supplementing with snacks.

This pt was on isolation precautions and had several issues that I was on the phone with the doctor and lab about. We needed blood cultures and to start a new abx. I had to wait for lab to come to get the culture before I could begin the new antibiotic. The order was to get one from his portacath and one peripheral and if unable to obtain form the portacath (which I knew would happen as his pc didn't return) then two peripherals.

So, I was trying to group his care d/t his being on isolation. After all was said and done, I ended up getting the new antibiotic going (late because lab was dragging their feet) and after it was running I discovered his blood sugar was 46. Now, by this time, I had been in his room for about 30 minutes and still had things to do (drsg changes,etc). I knew good and well that the protocol was to give d50 by IV but he was completely asymptomatic. I decided to give him juice and crackers, let him eat that while I was doing the other stuff and recheck the blood sugar and if it was still low go for the d50.

My rational for this was:

1. He was asymptomatic and the juice and crackers may do just fine. I'd be in the room with him monitoring him the whole time.

2. Why stop the abx, even if just for a brief time unless absolutely necessary PLUS unhooking the abx and opening up that central line= more opportunity for infection.

3. This one is sort of selfish: I could call out and have someone bring me the snacks which frees me from having to ungown and regown.

4. He has a history of getting pretty low but comes right back up.

Well, he did just fine with the juice and crackers. His blood sugar was near 80 within fifteen minutes. I felt like I made a decent choice based on good rationales. However, when giving report to the oncoming nurse, the nurse flipped out. They were incredibly concerned that I did not follow protocol. Now I'm second guessing my decision.

I'm a new nurse with just at a year under my belt. I'm open to any tips, criticisms, etc. I really just want to learn and do what is right and in the best interest of my pts.

What do you think? Was I totally out of line? Should I have just followed the protocol?

[turnforthenurse, MSN, NP]

My hospital has had one patient, who as best we can guess, died due to D50. The patient was a severe vasculopath with near daily MI's, within 60 seconds of getting an amp D50 by central line the patient went into VT/VF and couldn't be revived. Injecting D50 is basically like giving stomach acid IV, except it's more syrupy, and should be avoided whenever possible.

Yikes. I believe it, though.

The pH of D50 is 4 (but there are other drugs that are even more acidic, like vancomycin) and the osmolality is >1,000. That's why if possible the least invasive (oral supplementation) should be tried first with hypoglycemia unless of course the patient is unresponsive. And another reason why these meds should be administered through a central line if at all possible.

[psu_213, BSN, RN]

Not to get too far off subject, but I have noticed the vast majority of prehospital episodes of hypoglycemia are treated by medics with D50 (assuming they can get IV access), even if the pt is able to take PO. Obviously in those those cases, the D50 is not given by central line. The again, one of our local municipality's medics have a very strong union, and they can get away with almost whatever they want.

[MunoRN, RN]

Not to get too far off subject, but I have noticed the vast majority of prehospital episodes of hypoglycemia are treated by medics with D50 (assuming they can get IV access), even if the pt is able to take PO. Obviously in those those cases, the D50 is not given by central line. The again, one of our local municipality's medics have a very strong union, and they can get away with almost whatever they want.

I have many medic friends and mean no offense, but given the option, medics almost always chose the most aggressive route possible, even when totally unnecessary, especially if it involves starting an IV, or better yet 5 IV's.

[NursEMT-P]

As a medic, I can only speak for my service in saying that we ALWAYS choose feeding the patient over D50, and I know very few people who would say differently. That being said, we are almost always called after the patient is found unconscious or after reasonable lay person efforts to raise BG, when D50 is necessary. D50 can be very detrimental to the patient for a number of reasons (super sugar high and a big crash, vein damage, extravasation and subsequent major tissue damage, trouble regulating blood sugar for days afterwards in severe DM and osmolality concerns) and I know many medical directors who are taking a long hard look at how diabetic patients are treated for this very reason. I think you made the right choice, I would never question your judgement and I would venture to say that following a protocol just for the sake of it without using judgement is much more dangerous then the common sense you exercised! Good job!!

[RainMom]

My facility does not even keep D50 anymore. Found that out when I had a symptomatic BS of 32. Fairly alert & able to eat, but I also felt more comfortable giving D50 as well. Pyxis auto subs D10 to run over 15-30 min depending if for 1/2 amp or full amp. I was like "What? I have to prime tubing?!" I'm told it's cheaper to carry/use the D10.

[IVRUS, BSN, RN]

First of all, It truly puzzles me why nurses in a hospital setting aren't proactive and getting orders for Cathflo when ANY central line doesn't yeild a blood return. A central line that doesn't yield a blood return is a non-functioning IV catheter.

I would NOT have pushed an amp of D50 into this central line, however, if it wasn't giving me a brisk return. I would have started a peripheral and gave the dextrose. Remember it is the osmolarity of an amp of D50 you are worrrying about. Anything over 600 is quite damaging to the peripheral vascualture. An amp of D50 has an osmolarity of over 2500. Ouch!

So, his port should have patency restored to it, so you wouldn't have this concern when giving it.

[VANurse2010]

At my facility, only ICU and dialysis nurses (and probably ED too, but I'm not sure) can administer Cathflo. It isn't always possible for that to happen, depending on time of day and staffing. That's a bit of an aside, but I thought I'd bring it up since we're talking about clogged central lines.