What is the protocol for 5% dextrose (Dextrose, a type of glucose) infusion to manage starvation ketonemia in patients fasting for surgery?

Protocol for 5% Dextrose Infusion for Starvation Ketonemia in Surgical Fasting

For patients with starvation ketonemia due to surgical fasting, administer 5% dextrose infusion at a rate of 5-7 mg/kg/min to prevent hypoglycemia and reverse ketosis while maintaining blood glucose between 100-180 mg/dL (5.5-10 mmol/L). 1

Rationale and Background

Prolonged fasting before surgery can lead to starvation ketonemia, a metabolic state where the body produces ketone bodies due to depleted glycogen stores. This is particularly concerning as:

• Fasting periods of >13 hours can lead to metabolic acidosis and ketonemia in surgical patients
• Starvation ketosis can worsen surgical outcomes and increase metabolic stress
• Providing glucose helps suppress ketogenesis and prevents hypoglycemia

Administration Protocol

Preparation and Dosing

1. Use 5% dextrose solution (5g/100mL) in appropriate IV bags (250mL, 500mL, or 1000mL) 2
2. Calculate the infusion rate based on patient weight:
   • Target infusion rate: 5-7 mg/kg/min of dextrose 1
   • For a 70kg adult, this equals approximately 100-150 mL/hour of 5% dextrose

Administration Route

• Use peripheral IV for 5% dextrose (acceptable osmolarity)
• Consider central venous access for concentrations >5% or if peripheral vein irritation occurs 2

Monitoring Requirements

• Check blood glucose:
  • Before starting infusion
  • 30-60 minutes after starting infusion
  • Every 2-4 hours during continued infusion
• Target blood glucose: 100-180 mg/dL (5.5-10 mmol/L)
• Monitor for signs of hyperglycemia or hypoglycemia

Special Considerations

Diabetic Patients

• More frequent glucose monitoring (hourly initially)
• Consider adding insulin to the protocol if blood glucose exceeds 180 mg/dL (10 mmol/L) 1
• Initial insulin dose: 0.1 U/g dextrose if needed 1

Timing Considerations

• Begin infusion when patient is NPO (nothing by mouth)
• Continue until oral intake is resumed
• For prolonged procedures or delayed oral intake, maintain infusion to prevent recurrence of ketosis

Potential Complications

1. Hyperglycemia

   • Risk increases with higher infusion rates
   • Even 500mL of 5% dextrose can cause transient hyperglycemia in non-diabetic patients 3
   • If glucose >180 mg/dL (10 mmol/L), reduce infusion rate

2. Fluid Overload

   • Monitor fluid balance, especially in patients with cardiac or renal impairment
   • Adjust rate based on overall fluid requirements and patient status

3. Electrolyte Imbalances

   • Consider adding electrolytes for prolonged infusions
   • Monitor serum sodium, potassium, and chloride if infusion continues >24 hours

Discontinuation Protocol

1. Maintain infusion until patient can resume oral intake
2. Once oral intake is established, gradually taper infusion over 1-2 hours
3. Monitor blood glucose 1-2 hours after discontinuation to ensure stability

Evidence-Based Outcomes

Research shows that appropriate glucose administration during surgical fasting:

• Reduces insulin resistance and metabolic stress response to surgery 4
• Prevents hypoglycemia without causing significant hyperglycemia when properly dosed
• Improves patient comfort by reducing symptoms of starvation ketosis

The key to successful management is maintaining blood glucose within target range while providing sufficient glucose to suppress ketogenesis and prevent the metabolic consequences of prolonged fasting.