ALL SUGARS ARE NOT SWEET

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