One Ampule of D50: What is it Worth?
ABSTRACT & COMMENTARY
Source: Balentine JR, et al. Effect of 50 milliliters of 50% dextrose in water administration on the blood sugar of euglycemic volunteers. Acad Emerg Med 1998;5:691-694.
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. The risks and benefits of empiric therapy with D50 have been evaluated extensively.1 However, one great mystery remains: if the clinician chooses to administer D50, how high will the patient's glucose be elevated, and how long can it be expected to remain elevated?
Preliminary work in the ED in 51 patients with altered mental status used fixed D50 dosing and a single post-administration glucose sample taken at an imprecise time.2 Balentine and associates suggested that serum glucose could not be predicted because, although the glucose in their patients rose a mean of 166 mg/dL, the range was from 37-370 mg/dL. In this paper, Balentine et al attempted to resolve this issue. Twenty-five normal volunteers were all given one ampule of D50 by intravenous bolus and underwent multiple glucose samplings at rigorous intervals. Serum glucoses rose from a mean of 82.3 ± 13.5 mg/dL to 244.4 ± 44.6 mg/dL at five minutes, and all returned to baseline by 30 minutes.
COMMENT BY ROBERT HOFFMAN, MD
Although the results of this paper suggest that a predictable rise and fall in serum glucose can be achieved, and that a single ampule of D50 seems to be adequate even in profound hypoglycemia, several significant limitations of the study need to be addressed. First, all of the volunteers were given a standard dose of glucose. It might have been more precise to have given them all a dose that was adjusted for body weight, approximating the common guideline of 0.5-1 g/kg.1 By random errors, this study flaw may have actually made the data appear better than they are. Also, the use of normal individuals with normal baseline glucoses limits any extrapolation of these data to patients with altered mental status, patients with extremes of glucose values, or those with disorders or medications that alter glucose handling. It is conceivable that the 300-pound diabetic patient with hypoglycemia from an insulin overdose will respond differently to a single ampule of D50 than the healthy lean human volunteer.
Despite these limitations which Balentine et al acknowledge, this research makes a significant contribution to our understanding of glucose handling. Clearly, the next step is to use this methodology in actual hypoglycemic patients. For now, it is important to remember that the duration of effect of a single bolus of dextrose is short, and patients with hypoglycemia need frequent clinical and numerical reassessment of their status.
References
1. Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness: Controversies in the use of a "coma cocktail." JAMA 1995;274:562-569.
2. Adler PM. Serum glucose changes after administration of 50% dextrose solution: Pre- and in-hospital calculations. Am J Emerg Med 1986;4:504-506.
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