From the Guidelines
If blood glucose levels (BGL) continue to drop despite D50W administration, immediate escalation of treatment is necessary, and repeating the D50W bolus and starting a continuous D10W infusion is crucial to prevent further complications. According to the 2024 American Heart Association and American Red Cross guidelines for first aid 1, untreated hypoglycemia can cause seizures, status epilepticus, permanent brain injury, and death, emphasizing the need for prompt action. The guidelines suggest that intravenous dextrose can be lifesaving for people with hypoglycemia who are unable to swallow.
Given the ongoing drop in BGL despite initial D50W administration, it is essential to:
- Repeat the D50W bolus (25-50g) to rapidly restore blood glucose levels
- Simultaneously start a continuous D10W infusion at 100-125 mL/hour to maintain euglycemia, as the body rapidly metabolizes dextrose, particularly in hyperinsulinemic states 1
- Consider administering glucagon 1mg IM/IV/SC for persistent hypoglycemia, especially if IV access is difficult
- Monitor BGL closely every 15-30 minutes until stable, then hourly, to prevent further complications
The continued drop in glucose despite D50W suggests either severe ongoing insulin effect, sulfonylurea overdose, critical illness, or inadequate initial dextrose dosing. For patients with recurrent hypoglycemia, admission for observation and investigation of underlying causes is warranted, as this could indicate serious conditions like insulinoma, adrenal insufficiency, or medication effects requiring specific treatment 1.
From the FDA Drug Label
The solution is also indicated, after dilution, for intravenous infusion as a source of carbohydrate calories in patients whose oral intake is restricted or inadequate to maintain nutritional requirements. Slow infusion of hypertonic solutions is essential to ensure proper utilization of dextrose and avoid production of hyperglycemia.
The patient's blood glucose level (BGL) is still dropping after administration of intravenous D50W. The FDA drug label indicates that D50W is used to restore blood glucose levels, but it does not provide information on what to do if the BGL continues to drop after administration.
- The label warns against rapid administration of hypertonic solutions, which can cause hyperglycemia and hyperosmolar syndrome 2.
- It is essential to slowly infuse the hypertonic solution to ensure proper utilization of dextrose and avoid production of hyperglycemia 2. Given the information provided, it is unclear why the patient's BGL is still dropping, and the label does not provide guidance on next steps.
From the Research
Blood Glucose Response to D50W
- The administration of intravenous D50W is a common treatment for hypoglycemia, but it may not always be effective in correcting blood glucose levels (BGLs) 3.
- A study found that the use of D50W resulted in a higher post-treatment glycemic profile compared to D10W, with a mean increase of 3.2mmol/L 3.
- Another study analyzed the blood glucose response to D50W in critically ill patients and found that the overall median blood glucose response was 4.0 mg/dL per gram of D50W administered 4.
Factors Affecting Blood Glucose Response
- The response to D50W can be affected by various factors, including the presence of diabetes, recurrent hypoglycemia, and insulin infusion rate 4.
- Patients with diabetes were found to have a significantly higher blood glucose response to D50W, while those with recurrent hypoglycemia had a lower response 4.
- The response to D50W also increased with increasing insulin infusion rate 4.
Alternative Treatments
- The use of D10W has been proposed as an alternative to D50W, with studies suggesting that it may be as effective in resolving symptoms and correcting hypoglycemia, but with fewer adverse events 3.
- However, the use of D10W may result in a slower resolution of symptoms, with a mean time to resolution of approximately 8.0 minutes compared to 4.1 minutes for D50W 3.