What are the recommendations for 5% dextrose (D5) versus 10% dextrose (D10) solutions in the management of Diabetic Ketoacidosis (DKA)?

From the Research

In the management of diabetic ketoacidosis (DKA), D5W (5% dextrose) is generally preferred over D10W (10% dextrose) once insulin therapy has lowered blood glucose to approximately 250 mg/dL, as recommended by the most recent and highest quality study 1. This approach is based on the principle of preventing hypoglycemia while allowing continued insulin administration to clear ketones. The lower concentration of dextrose in D5W provides sufficient glucose to prevent hypoglycemia without causing significant hyperglycemia that could delay ketone clearance.

Key Considerations

• The management of DKA requires hospitalization for aggressive intravenous fluids, insulin therapy, electrolyte replacement, and identification and treatment of the underlying precipitating event, along with frequent monitoring of the patient's clinical and laboratory states 2.
• The most common precipitating causes for DKA include infections, new diagnosis of diabetes, and nonadherence to insulin therapy, and clinicians should be aware of the occurrence of DKA in patients prescribed sodium-glucose co-transporter 2 inhibitors 2.
• The use of D10W is generally reserved for cases of more severe hypoglycemia or when fluid restriction is necessary, and the insulin infusion rate can be adjusted to maintain a minimum dose of 0.05-0.1 units/kg/hour to continue addressing ketosis.

Management Approach

• Once insulin therapy has lowered blood glucose to approximately 250 mg/dL, D5W should be added to the intravenous fluids at a rate of 150-250 mL/hour while continuing insulin therapy.
• If blood glucose falls below 150-200 mg/dL, the dextrose concentration can be increased or the insulin infusion rate can be decreased, while maintaining at least the minimum insulin dose to continue addressing ketosis.
• The rationale behind this approach is that insulin is needed continuously to suppress ketogenesis and promote ketone clearance, even after blood glucose has normalized, and providing appropriate dextrose allows this insulin therapy to continue safely until the metabolic derangement is fully corrected 1.