mL Of D5W Research Articles

Comparison of Ultrasound-Guided Hydrodissection with Various Volumes of 5% Dextrose for Carpal Tunnel Syndrome: A Prospective Randomized Controlled Double-Blind Trial.

Ideal volume of 5% dextrose (D5W) for median nerve hydrodissection (HD) for treating carpal tunnel syndrome (CTS) is still unknown. This study assessed the efficacy of nerve hydrodissection using varying volumes of D5W for treating mild to moderate CTS. Eighty participants with unilateral mild to moderate CTS were randomized into groups to receive either 5 ml of normal saline (NS), 5 ml of D5W, 10 ml of NS, and 10 ml of D5W, with each group undergoing one session of ultrasound-guided HD. Visual Analogue Scale (VAS), Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), grip and pinch strength, cross-sectional area (CSA) of median nerve, and electrophysiological assessment were performed at baseline and weeks 4 and 12. In the 10 ml D5W group, VAS scores considerably improved compared with those in the NS groups. Although nerve CSA values decreased in all groups during follow-ups, the 10 mL D5W group showed a statistically significant improvement compared to the NS groups by the 12th week (p ≤ 0.01). Ultrasound-guided median nerve HD with 10 ml D5W was more effective in reducing pain and nerve size than the NS groups at the 12th week.

Sodium bicarbonate in 5% dextrose: can clinicians tell the difference?

Due to the lack of double-blind randomised controlled trials, the true effect of intravenous sodium bicarbonate therapy in ICU patients with metabolic acidosis remains unclear. We diluted 100 mL 8.4% sodium bicarbonate in 150 mL 5% dextrose (D5W) within a 250 mL polyolefin bag after removing 100 mL. We asked ICU clinicians to inspect a 250 mL bag containing sodium bicarbonate or a 250 mL bag where 100 mL of D5W had been removed and then returned. The bags were attached to intravenous giving sets. We asked participants to identify the contents of the bags. Among 60 participants (39 nursing staff [65%], 20 medical staff [33.3%] and one pharmacist), 36 (60%) answered correctly. The Cohen κ for agreement between test bag content and participants' answers was 0.20 (95% CI, -0.05 to 0.45; P = 0.12), implying the answers were correct by chance. In the group of 28 participants who indicated they used a clue to help them decide their answer, 15 (53.6%) answered correctly, whereas in the remainder (n = 32), 21 (65.6%) answered correctly (P = 0.49). When 100 mL of 8.4% sodium bicarbonate were diluted in 150 mL of D5W within a 250 mL polyolefin bag, clinicians were unable to correctly identify the contents of the bags. Our findings imply that sodium bicarbonate therapy can be successfully blinded.

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain.

Objectives: Chronic low-back pain (CLBP) participants in a prior controlled study reported short-term pain relief after caudal epidural injection of 5% dextrose (D5W). This study assessed whether repeated caudal epidural injections of D5W results in serial short-term diminution of CLBP and progressive long-term decrease in pain and disability.Design: Prospective uncontrolled study.Settings/Location: Outpatient pain clinic.Subjects: Adults with CLBP with radiation to gluteal or leg areas.Interventions: Caudal epidural injection of 10 mL of D5W (without anesthetic) every 2 weeks for four treatments and then as needed for 1 year.Outcome measures: Numerical Rating Scale (NRS, pain, 0–10 points), Oswestry Disability Index (ODI, disability, %), and fraction of participants with ≥50% reduction in NRS score. Analysis by intention to treat.Results: Participants (n = 32, 55 ± 9.8 years old, nine female) had moderate-to-severe CLBP (6.5 ± 1.2 NRS points) for 11.1 ± 10.8 years. They received 5.5 ± 2.9 caudal D5W injections through 12 months of follow-up. The data capture rate for analysis was 94% at 12 months for NRS and ODI outcome measures, with 6% carried forward by intention to treat. A consistent pattern of analgesia was demonstrated after D5W injection. Compared with baseline status, NRS and ODI scores improved by 3.4 ± 2.3 (52%) and 18.2 ± 16.4% (42%) points, respectively. The fraction of participants with 50% reduction in NRS-based pain was 21/32 (66%).Conclusion: Epidural D5W injection, in the absence of anesthetic, resulted in consistent postinjection analgesia and clinically significant improvement in pain and disability through 12 months for most participants. The consistent pattern postinjection analgesia suggests a potential sensorineural effect of dextrose on neurogenic pain.

Cephalothin Stability in Normal Saline, Five Percent Dextrose in Water, and Dianeal® Solutions

ABSTRACT The stability of cephalothin sodium (1 g) in polyvinyl chloride minibags containing 50 mL of 0.9% normal saline, 5% dextrose in water (D5W) or 500 mg in 2L of Dianeal® (containing 1.5% or 4.5% dextrose) was evaluated using a validated, stability-indicating, liquid chromatographic method during 30 days storage at 4° C and room temperature (23°C). Physical inspections and pH determinations also completed on each of the 11 study days during the 30 day storage period. During the 30-day study period all solutions lost more than 10% of the initial cephalothin concentration. In D5W and saline solutions stored at 4°C, 10% of the initial concentration was lost within 17 days, and at room temperature 10% was lost within one day. In Dianeal®, regardless of the dextrose concentration, solutions stored at 4°C, lost 10% of the initial concentration within eight days, and at room temperature 10% was lost within one day. During the 30-day study period the pH decreased in every solution. However, the decrease was less than 1.0 of a pH unit. The colour of solutions stored at room temperature gradually changed during the study period, becoming a deeper yellow. Solutions stored at °C remained clear and colourless throughout the study period. We conclude that cephalothin solutions (1 g/50 mL of D5W or normal saline) stored at 4°C for seven days followed by 12 hours storage at room temperature will retain 90% of the initial cephalothin concentration, whereas, cephalothin concentrations stored in Dianeal® (500 mg/2L) at 4°C will lose approximately 8% of the initial concentration after only three days storage at 4°C followed by an additional 12 hours storage at room temperature.

N-Acetylcysteine (NAC)-Induced Hyponatremia Caused by an Electronic Medical Record (EMR) Order Error

Intravenous N-acetylcysteine (NAC) causes few adverse drug events, with mild anaphylactoid reactions being the most common. Hyponatremia as a complication of hypoosmolar NAC solution has been reported. We describe how a locally constructed electronic medical record (EMR) order set for IV NAC resulted in a seizure from hyponatremia due to excess free water administration. A 13-month-old female with no past medical history presented to a hospital after ingesting an unknown number of acetaminophen 500 mg tablets. The 4-h acetaminophen concentration was 343 mcg/mL, and she was started on IV NAC. 8.2 h into her 21-h IV NAC protocol, she developed a tonic-clonic seizure. Repeat serum sodium was 124 mEq/L, a decrease from 142 mEq/L at the time of admission. She was treated with hypertonic saline, lorazepam, and levetiracetam and had no further seizures. A brain MRI and EEG were both normal. After the seizure was stabilized, the providers noticed that the patient had receive a total of 900 mL of D5W (112.5 mL/kg) in the first 9 h of hospitalization. This was caused by a poorly constructed, restrictive, EMR order set that did not allow customization of the IV NAC preparation. Because the 21-h IV NAC administration involves preparation of 3 different doses infused over 3 different time intervals, an order set was developed to reduce ordering errors. However, error in its construction caused the pharmacist to prepare a solution containing too much free water, decreasing patient's intravascular sodium and resulting in a seizure. The purposes of our case report were to highlight the dangers of overreliance on EMR order sets and to recognize hyponatremic seizures as an adverse reaction of an inappropriately prepared IV NAC.

Ultrasound-Guided Perineural Circumferential Median Nerve Block With and Without Prior Dextrose 5% Hydrodissection

Ultrasound-guided perineural peripheral nerve block using a hydrodissection technique may reduce the risk of accidental intravascular local anesthetic (LA) injection. In this prospective randomized double-blind study, we tested the hypothesis that median nerve block effectiveness is not reduced when circumferential perineural hydrodissection with dextrose 5% in water (D5W) precedes LA injection. Patients scheduled for hand surgery were randomized to receive an ultrasound-guided median nerve block at the elbow to achieve circumferential perineural spread with either 6 mL of D5W followed by 6 mL of LA (lidocaine 1.5% with epinephrine 1:200,000) (D5W-LA group) or with 6 mL of LA alone (LA group). The primary outcome was onset time of successful anesthesia defined by a complete abolition of light touch sensation for the index finger. Data from 95 patients were analyzed: 43 in the D5W-LA group and 52 in the LA group. Noninferiority tests were significant (all P < 0.05) for a critical limit of 7 minutes between D5W-LA and LA groups for onset time of the primary criterion, light touch block at index finger (mean ± SD, respectively: 23.9 ± 7.4 and 22.0 ± 7.9 minutes; 95% confidence interval [CI], -5.9 to 2.1 minutes), and for cold block at index fingertip, sensory blocks at thenar eminence, and motor block. Success rate at 30 minutes (defined as complete abolition for cold and light touch at index finger) was noted in 100% and 98.1% (95% CI, -6% to 10%) and 95.2% and 96.2% (95% CI, -13% to 9%) of patients for the D5W-LA and the LA groups. Performing an ultrasound-guided perineural circumferential hydrodissection with D5W into which LA is injected leaves nerve block outcome unchanged. The assumption that this procedure may reduce the risk of intravascular injection and systemic toxicity remains to be demonstrated.

Stability of norepinephrine infusions prepared in dextrose and normal saline solutions

Norepinephrine (NE) infusions are commonly used in the intensive care unit and in the operating room. Data on long term stability of NE solutions are lacking. This prospective study was designed to evaluate the stability of NE, in dextrose (5%) in water (D5W) and in normal saline (NS) solutions, for a period up to seven days. We prepared norepinephrine solutions in quadruplicate, by aseptically diluting 1 mg NE in 250 mL of D5W or NS and 4 mg NE in 250 mL of D5W or NS (final concentrations, 4 microg x mL(-1) and 16 micro x mL(-1), respectively) and stored the solutions at room temperature under ambient light. We sampled the solutions, in duplicate, at times 0, 24, 48, 72, 120, and 168 hr and stored them at -80 degrees C for later assay. Norepinephrine concentrations were measured by high-performance liquid chromatography with electrochemical detection (coefficient of variation 4.6%). Statistical analysis was done by nonparametric, repeated measures ANOVA (Friedman test). There was no significant decrease in NE concentration for either, NE 4 microg x mL(-1) in D5W or NS (P = 0.09 and 0.11, respectively) or for NE 16 microg x mL(-1) in D5W or NS (P = 0.18 and 0.40, respectively). The ratios of NE concentration at 168 hr, compared to baseline, were 95.7% and 96.4%, for NE 4 microg x mL(-1) in D5W and NS, respectively, and 104.5% and 96.4%, for NE 16 microg x mL(-1) in D5W and NS, respectively. Norepinephrine solutions, in concentrations commonly used in the clinical setting, are chemically stable for seven days, at room temperature and under ambient light, when diluted either in D5W or NS.

A Revised Argatroban Infusion Strategy Produces a Significant In-Patient Pharmacy Cost Avoidance.

Background: Argatroban (ARG) is a synthetic direct thrombin inhibitor (DTI) derived from L-arginine. ARG is approved in the U.S. for the prophylaxis or treatment of thrombosis in HIT and in pts. with or at high risk of HIT undergoing PCI. At our Institution, 254 (56%) of HIT Registry DTI-treated pts. received ARG from 1.99–12.05. In 2005, ARG accounted for 5.1% ($1,294,967) of our annual pharmacy acquisition costs and ranked #1 in single-agent costs.Objective: To assess the impact of ARG on pt. use/24 hr, drug waste, and inpatient pharmacy average wholesale price (AWP; 2006) acquisition costs with 250 mg/250 ml D5W or NS for 24-hr. pt. titration before expiration (“Standard Formulation” group; SF) compared with 250 mg/250 ml or 100 mg/100 ml of D5W or NS with a 96-hr. infusion expiration date using light-resistant measures (“Revised Formulation” group; RF).Design: Retrospective study utilizing a SF (1.1.06–5.31.06) vs. RF (6.1.06–7.14.06) treatment strategy; prospective drug utilization time-study (SF: 5.23.06–6.1.06).Patients: Pts. with, a history of, or at high-risk for HIT ± thrombosis.Setting: Tertiary-care health care system; IRB-approved HIT Registry.Measurements: Pt. days on ARG; vial utilization/pt. day; 2006 AWP acquisition cost/vial (250 mg) for ARG ($1,139); drug utilization time-study (dose and infusion rate/pt.; drug waste); 12-month AWP acquisition cost projection analysis.Results: In the SF group, 118 pts. received ARG for 962 pt. days with a mean of 6.4 (range, 3–13) pts. treated/day. A total of 883 vials of ARG were purchased at a mean of 177 (range, 139–224) vials/mo. with a mean of 0.92 (range, 0.75–1.03) vials utilized/pt day. In the SF group, the total acquisition cost, mean cost/mo. and per pt. day was $1,005,737, $201,147 (range, 158,321–255,136) and $1,048 (range, 854–1173), respectively. A 10-day time study was performed in 8 SF group pts. to determine ARG utilization parameters for the RF group. This showed a mean initital IV dose of 1.12 (range, 0.5 to 2.0) mcg/kg/min., a mean maintenance dose of 1.04 (range, 0.06–2.0) mcg/kg/min. The mean infusion volume was 5.1 (range, 0.32–9.2) ml/hr. The mean treatment and drug wastage volumes were 122 (range, 7.7–221) ml/24 hr/pt. and 128 (range, 29 to 242) ml/24 hr/pt. The subsequent RF group with a 96 hr. infusion expiration date included 18 pts. who received ARG at 250 mg/250 ml (6.1.06–6.18.06) and 25 pts. who received ARG at 100mg/100ml (6.19.06–7.14.06). In the RF group, 43 pts. received ARG for 292 pt. days with a mean of 6.6 (range, 1–12) pts. treated/day. A total of 134 vials were purchased with a mean of 0.46 vials utilized/pt. day. In the RF group, the total AWP acquisition costs and mean cost/pt. day were $152,626 and $524, respectively. A 12-mo. acquisition cost projection analysis was performed with the following assumptions: 1254 pt. days on ARG (1.1.06–7.14.06); vial use/pt. day: SF group (0.92), RF group (0.46); and the 2006 AWP acquisition cost/vial of ARG. This analysis showed projected 12-mo. acquisition costs of $2,459,374 for the SF group and $1,229,687 for the RF group. The projected annualized cost avoidance in pharmacy 2006 AWP acquisition costs with the RF strategy was $1,229,687/yr. (mean $102,474/mo.).Conclusions: We conclude that a revised formulation strategy for ARG administration can produce significant cost avoidance in hospital pharmacy AWP acquisition costs. An analysis of patient characteristics and indications for ARG will be presented.

Part 7.4: Monitoring and Medications

This section provides an overview of monitoring techniques and medications that may be useful during CPR and in the immediate prearrest and postarrest settings. ### Assessment During CPR At present there are no reliable clinical criteria that clinicians can use to assess the efficacy of CPR. Although end-tidal CO2 serves as an indicator of cardiac output produced by chest compressions and may indicate return of spontaneous circulation (ROSC),1,2 there is little other technology available to provide real-time feedback on the effectiveness of CPR. ### Assessment of Hemodynamics #### Coronary Perfusion Pressure Coronary perfusion pressure (CPP = aortic relaxation [diastolic] pressure minus right atrial relaxation phase blood pressure) during CPR correlates with both myocardial blood flow and ROSC (LOE 3).3,4 A CPP of ≥15 mm Hg is predictive of ROSC. Increased CPP correlates with improved 24-hour survival rates in animal studies (LOE 6)5 and is associated with improved myocardial blood flow and ROSC in animal studies of epinephrine, vasopressin, and angiotensin II (LOE 6).5–7 When intra-arterial monitoring is in place during the resuscitative effort (eg, in an intensive care setting), the clinician should try to maximize arterial diastolic pressures to achieve an optimal CPP. Assuming a right atrial diastolic pressure of 10 mm Hg means that the aortic diastolic pressure should ideally be at least 30 mm Hg to maintain a CPP of ≥20 mm Hg during CPR. Unfortunately such monitoring is rarely available outside the intensive care environment. #### Pulses Clinicians frequently try to palpate arterial pulses during chest compressions to assess the effectiveness of compressions. No studies have shown the validity or clinical utility of checking pulses during ongoing CPR. Because there are no valves in the inferior vena cava, retrograde blood flow into the venous system may produce femoral vein pulsations.8 Thus palpation of a pulse in the femoral triangle may indicate venous rather than arterial …

The Electrophysiological Effect of Dextrose 5% in Water on Single-Shot Peripheral Nerve Stimulation

When performing regional anesthesia, a small volume of local anesthetic or normal saline abolishes a motor response induced by a low current (0.5 mA). In this case series we describe the electrophysiological effect of a nonconducting (dextrose 5% in water, D5W) injectate on a motor response elicited by low current electrical stimulation. Twenty-nine peripheral nerve blocks were performed in 20 patients using insulated needles. Each needle was primed with D5W. The needle was advanced towards the target nerve until corresponding motor responses were observed using a current of 0.5 mA or less. Once the needle position was optimally placed, 1 mL of D5W was injected followed by a predetermined dose of local anesthetic. The effects of the injectates (D5W and local anesthetic) on the motor response were observed at all needle insertion sites. In all cases, the motor response was at least maintained or augmented (96%) immediately after the injection of D5W. All motor responses diminished after the injection of local anesthetic (100%). All blocks were considered clinically successful.

Dextrose 5% in water: fluid medium for maintaining electrical stimulation of peripheral nerves during stimulating catheter placement

It is well documented that a higher electrical current is required to elicit a motor response following a normal saline (NS) injection during the placement of stimulating catheters for peripheral nerve block. We present three cases of continuous brachial plexus catheter placement in which Dextrose 5% in water (D5W) was used to dilate the perineural space instead of NS. Three brachial plexus blocks (two interscalene and one axillary) were performed in three different patients for pain relief. In each case, an insulated needle was advanced towards the brachial plexus. A corresponding motor response was elicited with a current less than 0.5 mA after needle repositioning. A stimulating catheter was advanced with ease after 3-5 ml of D5W was injected to dilate the perineural space. A corresponding motor response was maintained when the current applied to the stimulating catheter was less than 0.5 mA. Local anesthetic was then injected and the motor response immediately ceased. All blocks were successful and provided excellent pain relief with the continuous infusion of local anesthetics.

Part 6: Advanced Cardiovascular Life Support

Part 6: Advanced Cardiovascular Life Support

BOLUS MAGNESIUM INFUSION IN HUMANS IS ASSOCIATED WITH PREDOMINANTLY UNFAVOURABLE CHANGES IN PLATELET AGGREGATION AND CERTAIN HAEMOSTATIC FACTORS

The purpose of this study was an attempt to extrapolate favorable observations on the effects of magnesium on platelets and haemostasis from animal models to humans. Intravenous magnesium in the treatment of acute myocardial infarction has been tested in several large clinical trials and remains controversial. The mechanism for the cardioprotective properties of magnesium is unknown. Based on experimental studies, several different hypotheses have been advanced to explain the benefits of magnesium including it's effects on platelets and haemostasis. However, few studies have analysed such a relationship in humans. This project was designed to assess the effect of bolus magnesium infusion onex vivoplatelet aggregation and certain haemostatic parameters in healthy volunteers. One gram of magnesium was diluted in 50 ml of D5W and infused over a period of 15 min. The changes of platelet aggregability, plasma antithrombin-III, Protein C, total Protein S, fibronectin, endothelin-1, as well as the metabolites of thromboxane and prostacyclin were determined prior to and immediately after magnesium infusion.Results:Serum magnesium concentration increased from 2.10±0.08 at baseline to 3.12±0.13 mg dl−1(P=0.0002) post-infusion. Magnesium infusion was associated with a significant elevation in ADP (+19.3%); ristocetin (+13.6%); and collagen-induced platelet aggregation (+14.2%); an increase in plasma antithrombin-III (+10.3%) and thromboxane (+49.4%) when compared to pre-infusion levels. Against this, total Protein S (−20.7%), Protein C (−11.2%) and ET-1 (−26.3%) plasma concentrations were markedly decreased. There were no significant differences in plasma fibronectin and prostacyclin levels. Contrary to expectations, magnesium infusion in human volunteers is associated with platelet activation and mostly small unfavourable changes in certain haemostatic factors. However, the observed changes were small and for the most part remained within the normal physiologic range.

Ciprofloxacin desensitization

Ciprofloxacin desensitization