What is the recommended initial infusion rate of D10 (dextrose 10%) for a patient in liver failure with hypoglycemia?

D10 Infusion Rate for Liver Failure with Hypoglycemia

For a patient with liver failure and hypoglycemia, D10 should be initiated at a rate of 100 mL/kg per 24 hours (equivalent to 7 mg/kg per minute) with appropriate maintenance electrolytes, and titrated to achieve normoglycemia. 1

Initial Management Approach

The management of hypoglycemia in liver failure requires prompt intervention due to the high risk of neurological complications. Liver failure impairs glucose homeostasis through multiple mechanisms:

• Decreased glycogen storage
• Impaired gluconeogenesis
• Altered insulin metabolism
• Increased peripheral glucose utilization

D10 Administration Protocol

1. Initial infusion rate:

   • 100 mL/kg per 24 hours (7 mg/kg per minute) 1
   • For a 70 kg adult, this equals approximately 290 mL/hour

2. Bolus dosing (if severe symptomatic hypoglycemia):

   • D10W: 0.5-1.0 g/kg (5-10 mL/kg) 1
   • For a 70 kg adult, this equals 350-700 mL of D10W

3. Monitoring:

   • Check blood glucose every 1-2 hours initially 1
   • More frequent monitoring (every 15-30 minutes) during titration phase
   • Target blood glucose: normal range (70-140 mg/dL)

Titration Strategy

The infusion rate should be adjusted based on blood glucose response:

• If glucose remains <70 mg/dL: Increase rate by 25%
• If glucose 70-140 mg/dL: Maintain current rate
• If glucose >140 mg/dL: Decrease rate by 25%

Titrate to achieve normoglycemia, as hyperglycemia can have adverse central nervous system effects in patients with liver failure 1.

Important Considerations

Blood Sampling Method

• Preferred method: Arterial or venous whole blood sampling 1
• Avoid: Finger-stick capillary blood glucose testing, which may be inaccurate in patients with poor perfusion 1

Fluid Management

• Exercise caution with fluid volume in patients with liver failure who may have ascites or be at risk for pulmonary edema
• Consider using D10 with half-normal saline if the patient needs both glucose and volume 1

Electrolyte Monitoring

• Monitor sodium, potassium, and phosphate levels regularly 1
• Hyponatremia is common in liver failure and should be corrected gradually 1

Advantages of D10 over D50

• Less risk of extravasation injury 2, 3
• Lower post-treatment hyperglycemia 2, 4
• More physiologic glucose correction 5

Ongoing Management

• Continue to monitor blood glucose at least every 2 hours in patients with severe liver failure 1
• Consider underlying causes of hypoglycemia in liver failure and address them if possible
• Evaluate for other metabolic derangements common in liver failure

D10 provides a more controlled glucose delivery compared to more concentrated solutions like D50, which is particularly important in liver failure where glucose regulation is impaired. The recommended initial rate allows for steady correction of hypoglycemia while minimizing the risk of rebound hyperglycemia.