ALL SUGARS ARE NOT SWEET

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Extravasation of vesicants occurs when there is leakage from a vessel into the surrounding area, with the potential to cause tissue necrosis. Common vesicants include vasopressors, alkylating chemotherapeutic agents, hyper-osmolar or hypo-osmolar agents, and certain antibiotics (vancomycin). Dextrose, at concentrations greater than 10% (D10), is also considered a vesicant, with rates of extravasation from 50% dextrose (D50) varying between 10-30% (1). CASE PRESENTATION: A cachectic 48-year-old with a history of HIV and alcohol and IV drug use, presented with lethargy. Upon initial assessment, she had track marks on her arms and was only responsive to sternal rub, with her exam otherwise unremarkable. She briefly improved with intravenous naloxone but ultimately required intensive care unit admission following intubation for airway protection. The toxicology screen was positive for methadone, opioids, and alcohol. Initial labs revealed ALT of 118 units/L, AST of 94 units/L, hemoglobin of 9.5 g/dL, and albumin of 2.3 g/dL. She was started on thiamine, multivitamin, and folate supplements. Despite starting tube feeds, fingerstick (FS) glucose was consistently low, dropping to 35 mg/dL. She received 2 ampules of 50 mL (25 g) 50% dextrose through a 22-gauge antecubital peripheral IV line, with FS improving to 220 mg/dL after 10 minutes. Two hours later, extensive swelling and fluid-filled blisters were noted throughout the forearm and hand, with Doppler ultrasound revealing the absence of a radial pulse. Her arm was elevated, a cold compress was applied, and a local subcutaneous injection of hyaluronidase was administered. Compartment pressures remained within normal limits, and a repeat Doppler ultrasound after an hour showed reappearance of a right radial pulse. The patient's swelling and blisters improved over the next few days. DISCUSSION: To the best of our knowledge, there are only three published cases on D50 extravasation so far, where D50 was administered by initial paramedic responders, in the field, in an emergent setting (1,2,3). D10 has a similar median time to recovery and post-treatment Glasgow Coma Scale, but with a decreased risk of rebound hyperglycemia. In our case, as the hypoglycemia incident occurred in an intensive care unit, administering D10 would have been a better option, as frequent FS monitoring would have been possible to assess response. Fortunately, close monitoring allowed for early recognition, prompt treatment, and good outcome. CONCLUSIONS: Hypoglycemia is a frequently encountered complication in a critical care setting. This case emphasizes the importance of early detection and treatment when suspecting extravasation of D50 to prevent the development of serious complications. D10 is now emerging as a safer and equally effective alternative to D50 and could become the standard of care for hypoglycemia management. REFERENCE #1: Wiegand R, Brown J. Hyaluronidase for the management of dextrose extravasation. Am J Emerg Med. 2010 Feb;28(2):257.e1-2. doi: 10.1016/j.ajem.2009.06.010. PMID: 20159411. REFERENCE #2: Chinn M, Colella MR. Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report. Prehosp Emerg Care. 2017 Jan-Feb;21(1):79-82. doi: 10.1080/10903127.2016.1209263. Epub 2016 Sep 6. PMID: 27598324. REFERENCE #3: Lawson SL, Brady W, Mahmoud A. Identification of highly concentrated dextrose solution (50% dextrose) extravasation and treatment--a clinical report. Am J Emerg Med. 2013 May;31(5):886.e3-5. doi: 10.1016/j.ajem.2012.12.010. Epub 2013 Apr 18. PMID: 23602753. DISCLOSURES: No relevant relationships by Natasha Garg, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Adam Rothman, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response