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Rural Medicine – Insulin OD

Mel Herbert, MD MBBS FAAEM, Vanessa Cardy, MD, Stuart Swadron, MD, FRCPC, and Sean Nordt, MD PharmD FAAEM
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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EM:RAP 2018 04 April Written Summary 535 KB - PDF

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Jon P. -

http://journals.aace.com/doi/pdf/10.4158/EP171780.CR?code=aace-site

Is this worth a try if you are running out of dextrose solutions the next time this happens?

Vanessa C. -

Thanks so much for your comment and the reference, and for listening!

Seth R. -

I had a strange thought not covered by the tox guys. What about giving oral glucose rectally? Giant mucus membrane. We give Tylenol and ASA this way all the time. If you're out of IV solution and not tolerating PO, why not? It may even have some slower, smoother absorption. I have never used this, but then I have never encountered this situation with all of the constraints you had. I am curious what the expert opinion would be.

Vanessa C. -

Really interesting thought Seth... Am going to ask my colleagues here at EMRAP to reach out to our pharmacy folks and get their opinion! Thanks for listening....

Vanessa C. -

Seth, here is a reply from Sean Nordt!

"Interesting idea and could also consider table sugar sucrose as would be widely available in addition to oral glucose. Sucrose is a disaccharide so not sure but if nothing else available.

More complex carbohydrates and proteins probably would not be absorbed due to lack of digestive enzymes in rectum

But I am not sure rectal glucose or sucrose would work to any great degree

There is a paucity of data, are ye surprised :)

The one human volunteer study did not show significant increase in blood glucose following rectal administration but did in same volunteers with cross over oral after three week washout period. They also noted large volume diarrhea, which would my concern with the large osmotic load
S. Attvall, et al.
Rectal glucose administration cannot be used to treat hypoglycemia
Diabetes Care 1985;4:412-413

There was a rat study that showed increased glucose levels following rectal administration. Complicated study and gave insulin at same time and cautious extrapolating these results
McGee D, et al. Dextrose is absorbed by rectum in hypoglycemic rats. J Emerg Med 2003;24:253-257

I do not have access to this one below but it apparently did not work and is in humans as well. Not study but case series

Aman J, et al. Treatment of hypoglycemia in diabetes: failure
of absorption of glucose through the rectal mucosa. Acta Paediatr
Scand 1984;4:560–1

What I recommend if I recall the case correctly if actively suicidal and/or altered and cannot place or keep NG tube in place and/or patient too altered to eat would intubate and document well why and place orogastric and give enteral dense nutrition formula ideally high in complex carbohydrates after initial glucose load

I think the risk of osmotic diarrhea in an altered patient with unknown absorption characteristics of rectal glucose decreases my recommending this route and would hate to "waste" if oral glucose paste was also limited as could use when mental status improves"

Nate M., DO -

Hi Vanessa
I found these compounding formulas online: can you confirm the safety?

To make a 1000 ml bag of D50
find some table sugar from the cafeteria
D50 is 25g in 50 ml so you can weight out what you feel is appropriate for your 1000 ml bag
youll need a small scale ( every pharmacy, kitchen, CVS) and a microwave to sterilize....or can give it orally

To make a bag of .9 NS
2 tsp of table salt in 1000ml bag or 4 cups of tap water is .9 NS

halve that....
1 tsp of table salt in 1000ml bag or 4 cups of tap water is .45 NS

youll need a small scale and a microwave to sterilize....or can give it orally

??

Vanessa C. -

You are all so McGuyverish! I love it!

Now while I can not confirm the safety of this, I am going to try and reach out to my pharmacy colleagues again and see what they say... Stay tuned, and thanks for listening and for writing in!

Vanessa C. -

Nate, I am afraid I don't have good news... But thanks for the question and for listening! See Sean Nordt's answer below.

Would not recommend any of these

In the United States would most likely be illegal in every state. Assume same for Canada and other countries.

Would need to a pharmacist with compounding pharmacy capabilities. Cannot make a parenteral medication without correct procedures and protections and pharmaceutical grade materials as would be illegal. Tap water has other compounds in it compared to sterile water for injection and dangerous to give parenterally.

Table sugar is sucrose not dextrose. Have to be also concerned about particulate matter that is not seen with the naked eye and can be dangerous to infuse. Putting in microwave most likely would not sterilize. Making own sodium chloride would be equally dangerous and "kitchen" type scales most likely not accurate enough to be safe.

You could make the sucrose solution to give orally but again if considered would recommend involve pharmacist even if by phone to verify and for legal protection. There is classic "simple syrup" solution more concentrated a pharmacist could help with BUT I still would not recommend doing either of these.

What I would recommend commercially available Lucozade or Gatorade and could add additional table sugar if needed. Has electrolytes to facilitate glucose absorption and easily available in most communities. In remote outposts probably not bad idea to stock a bunch. In Ireland that is what we used for oral glucose tolerance test.

Here is a pharmacist in the U.S. charged with killing patients due to fungal infections. http://www.newsweek.com/new-england-compounding-pharmacy-murder-trial-meningitis-outbreak-667111

So...long story short...would not recommend any homemade parenteral of those as too dangerous and improper for parenteral administration.

Great questions though

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