From the Guidelines
Dextrose-containing IV fluids should generally be avoided in diabetic patients unless they are experiencing hypoglycemia or have specific indications. For diabetic patients requiring IV hydration, normal saline (0.9% NaCl) or lactated Ringer's solution is typically preferred as the initial choice 1. If dextrose-containing fluids are necessary, close blood glucose monitoring is essential, with measurements every 1-2 hours initially, and insulin coverage should be provided according to the patient's needs.
Key Considerations
- For patients with severe hyperglycemia (blood glucose >250 mg/dL), avoid dextrose solutions entirely until glucose levels are controlled.
- In cases of hypoglycemia (blood glucose <70 mg/dL), D50W (50% dextrose) at 25-50 mL IV push is appropriate for immediate correction.
- For maintenance fluids in controlled diabetic patients who need some glucose, D5 1/2NS (5% dextrose in 0.45% saline) may be used with appropriate insulin coverage.
Rationale
The concern with dextrose-containing fluids in diabetics is that they can worsen hyperglycemia, leading to osmotic diuresis, dehydration, and potentially precipitating diabetic ketoacidosis or hyperosmolar hyperglycemic state. Each gram of dextrose provides 3.4 calories and can significantly impact blood glucose levels, requiring careful management in the diabetic population. According to the most recent guidelines, continuous intravenous insulin infusion is the most effective method for achieving specific glycemic goals and avoiding hypoglycemia in the critical care setting 1.
Monitoring and Management
- Blood glucose monitoring should be performed every 1-2 hours initially, and insulin coverage should be provided according to the patient's needs.
- The use of glucose meters has become common in hospitals, but clinicians must be aware of potential limitations in accuracy, especially in critically ill patients 1.
- Arterial or venous whole blood sampling is preferred over finger-stick capillary BG testing for patients in shock, on vasopressor therapy, or with severe peripheral edema 1.
From the FDA Drug Label
Solutions containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. To minimize hyperglycemia and consequent glycosuria, it is desirable to monitor blood and urine glucose and if necessary, add insulin.
Dextrose containing IV fluids should be used with caution in diabetic patients. It is recommended to monitor blood and urine glucose and add insulin if necessary to minimize hyperglycemia and glycosuria 2.
From the Research
Dextrose Containing IV Fluids in Diabetics
- The use of dextrose containing IV fluids in diabetics is a topic of interest, with studies examining the effects of different concentrations of dextrose on blood glucose levels and symptom resolution 3, 4.
- A systematic review comparing D50 (50% dextrose) and D10 (10% dextrose) found that D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia, with fewer adverse events 3.
- However, the study also found that the desired effect of D10 may take several minutes longer to achieve, and there may be a greater need for subsequent doses 3.
- Another study found that the use of 5% dextrose in 0.9% normal saline as an initial IV replacement fluid in elective surgery resulted in significant hyperglycemia in non-diabetic patients, suggesting that dextrose-containing fluids may not be necessary in all cases 4.
- In the context of diabetic ketoacidosis, a randomized controlled trial found no significant difference between Ringer's lactate and 0.9% sodium chloride solution in terms of time to normalization of pH, but the time to reach a blood glucose level of 14 mmol/l was significantly longer with Ringer's lactate solution 5.
- Other studies have examined the effects of different antacids on gastric secretion and the localization of phospholipases in subcellular fractions and plasma membranes, but these are not directly relevant to the use of dextrose containing IV fluids in diabetics 6, 7.
Key Findings
- D10 may be a suitable alternative to D50 for the treatment of hypoglycemia in diabetics, with fewer adverse events 3.
- The use of dextrose-containing IV fluids may result in significant hyperglycemia in non-diabetic patients 4.
- The choice of IV fluid in diabetic ketoacidosis should be based on individual patient needs and clinical judgment, rather than a one-size-fits-all approach 5.