Are we giving our patients a sweet chance at ROSC? Or consigning them to a sugary grave? We examine the evidence for and against Dextrose in Cardiac Arrest.
Two renown EMS blogs, Rogue Medic and Mill Hill Avenue Command, have already covered the topic before. But let’s take a deeper look at the evidence for and against Dextrose as well as discuss the cardiac physiology pertaining to Glucose metabolism. We’ll also cover how patients who become hypoglycemic end up going into cardiac arrest in the first place and whether we can accurately detect hypoglycemia in cardiac arrest.
Just like our Narcan podcast, we’re going to science and evidence the crap out of this one.
Here’s a breakdown of the points in this podcast.
- Myocardial cells don’t use glucose as a primary source of fuel. As little as 4% of myocardial ATP is generated from glucose.
- Giving dextrose during periods of ischemia increases anaerobic metabolism, promotes the conversion of pyruvate into lactate, causes intracellular acidosis, and may decrease cerebral blood flow, exacerbating cerebral ischemic injury.
- We can’t accurately determine blood glucose in cardiac arrest using capillary blood glucose. Glucometry using a venous sample without a venous reagent strip is suspect and potentially inaccurate.
- The largest study to date (Peng, 2015) shows worse overall survival to discharge.
- The largest study to date (Peng, 2015) shows worse neurologic outcome.
- The largest study to date (Peng, 2015) shows no association between dextrose administration and ROSC when propensity-matched analysis was used.
- Studies show even D5W can worsen outcomes in cardiac arrest.
Here’s the total body of evidence for Dextrose in cardiac arrest resuscitation (click to enlarge)…
The above data has been reproduced in accordance with the provisions of 17 U.S. Code § 107 “Fair Use” for the purposes of criticism, comment, and non-commercial educational purposes.
- Featured Image by Alden Chadwick (Flickr, Creative Commons License)
- Atkin, S. H., Dasmahapatra, A., Jaker, M. A., Chorost, M. I., & Reddy, S. (1991). Fingerstick glucose determination in shock. Annals of internal medicine, 12, 1020–1024.
- Meaney, P. A., B. J. Bobrow, and M. E. Mancini, et al. “Cardiopulmonary Resuscitation Quality: Improving Cardiac Resuscitation Outcomes Both Inside And Outside The Hospital: A Consensus Statement From The American Heart Association”. Circulation 128.4 (2013): 417-435. Web. 10 July 2016. DOI: 10.1161/CIR.0b013e31829d8654
- Boyd, R., Leigh, B., & Stuart, P. (2005). Capillary versus venous bedside blood glucose estimations. Emergency medicine journal : EMJ, 3, 177–179.
- Sylvain, H. F., Pokorny, M. E., English, S. M., Benson, N. H., Whitley, T. W., Ferenczy, C. J., & Harrison, J. G. (1995). Accuracy of fingerstick glucose values in shock patients. American journal of critical care : an official publication, American Association of Critical-Care Nurses, 1, 44–48.
- Thomas, S. H., Gough, J. E., Benson, N., Austin, P. E., & Stone, C. K. (1994). Accuracy of fingerstick glucose determination in patients receiving CPR.Southern medical journal, 11, 1072–1075.
- Kobayashi, K., & Neely, J. R. (1979). Control of maximum rates of glycolysis in rat cardiac muscle. Circulation research, 2, 166–175
- Holmes, D. R. (2007). Cardiovascular medicine (Third ed.). United Kingdom: Springer-Verlag New York.
- Sperelakis, N. (Ed.). (2011). Physiology and Pathophysiology of the heart. United States: Springer-Verlag New York.
- Drake, K. J., Sidorov, V. Y., McGuinness, O. P., Wasserman, D. H., & Wikswo, J. P. (2012). Amino acids as metabolic substrates during cardiac ischemia. Experimental Biology and Medicine, 237(12), 1369–1378. doi:10.1258/ebm.2012.012025
- Kammermeier, H., & Giesen, J. (1980). States of myocardial metabolism related to ischemia. Clinical Cardiology, 3(3), 197–199. doi:10.1002/clc.4960030308
- Weiss, R., & Maslov, M. (2004). Normal Myocardial Metabolism: Fueling Cardiac Contraction. Advanced Studies in Medicine, 4(6B), S457–S463.
- Peng, T. J., Andersen, L. W., Saindon, B. Z., Giberson, T. A., Kim, W. Y., Berg, K., Novack, V., Donnino, M. W., & , . (2015). The administration of dextrose during in-hospital cardiac arrest is associated with increased mortality and neurologic morbidity. Critical care (London, England), , 160.
- Anderson, R. V., Siegman, M. G., Balaban, R. S., Ceckler, T. L., & Swain, J. A. (1992). Hyperglycemia increases cerebral intracellular acidosis during circulatory arrest. The Annals of thoracic surgery, 6, 1126–1130.
- Rehncrona S, Rosén I, Siesjö BK. (1981). Brain lactic acidosis and ischemic cell damage. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism, 3, 297–311.
- D’Alecy, L. G., Lundy, E. F., Barton, K. J., & Zelenock, G. B. (1986). Dextrose containing intravenous fluid impairs outcome and increases death after eight minutes of cardiac arrest and resuscitation in dogs. Surgery, 3, 505–511.
- Browning, R. G., Olson, D. W., Stueven, H. A., & Mateer, J. R. (1990). 50% dextrose: antidote or toxin? Annals of emergency medicine, 6, 683–687.
- Wass, C. T., & Lanier, W. L. (1996). Glucose modulation of ischemic brain injury: review and clinical recommendations. Mayo Clinic proceedings, 8, 801–812.
- Müllner, M., Sterz, F., Binder, M., Schreiber, W., Deimel, A., & Laggner, A. N. (1997). Blood glucose concentration after cardiopulmonary resuscitation influences functional neurological recovery in human cardiac arrest survivors. Journal of cerebral blood flow and metabolism : official journal of the International Society of Cerebral Blood Flow and Metabolism, 4, 430–436.
- Nakakimura, K., Fleischer, J. E., Drummond, J. C., Scheller, M. S., Zornow, M. H., Grafe, M. R., & Shapiro, H. M. (1990). Glucose administration before cardiac arrest worsens neurologic outcome in cats. Anesthesiology, 6, 1005–1011.
- American Heart Association. (2015). Part 12: Pediatric advanced life support – ECC guidelines 2015. Retrieved July 10, 2016.
- Losek, J. D. (2000). Hypoglycemia and the ABC’S (sugar) of pediatric resuscitation. Annals of emergency medicine, 1, 43–46.
- Chopra, S., & Kewal, A. (2012). Does hypoglycemia cause cardiovascular events? Indian Journal of Endocrinology and Metabolism, 16(1), 102. doi:10.4103/2230-8210.91203
- Tattersall, R. B., & Gill, G. V. (1991). Unexplained deaths of type 1 diabetic patients. Diabetic medicine : a journal of the British Diabetic Association, 1,49–58.
- Beiser, D. G., Carr, G. E., Edelson, D. P., Peberdy, M. A., & Hoek, T. L. V. (2009). Derangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: A report from the national registry of cardiopulmonary resuscitation. Resuscitation, 80(6), 624–630. doi:10.1016/j.resuscitation.2009.02.011
- Longstreth, W. T., Diehr, P., Cobb, L. A., Hanson, R. W., & Blair, A. D. (1986). Neurologic outcome and blood glucose levels during out-of-hospital cardiopulmonary resuscitation. Neurology, 9, 1186–1191.
- Nolan, J. P., Neumar, R. W., Adrie, C., Aibiki, M., Berg, R. A., Böttiger, B. W., … Hoek, T. V. (2008). Post-cardiac arrest syndrome: Epidemiology, pathophysiology, treatment, and prognostication. Resuscitation, 79(3), 350–379. doi:10.1016/j.resuscitation.2008.09.017
- Walsh, B. (2012, March 14). Using Dextrose in Cardiac Arrest. Retrieved July 10, 2016, from Mill Hill Ave Command.
- Noonan, T. (2015, March 12). Dextrose in cardiac arrest – more kitchen sink medicine. Retrieved July 10, 2016, from Rogue Medic.