Is dextrose (glucose) infusion contraindicated in patients with stroke?

From the Guidelines

Dextrose infusion should generally be avoided in acute stroke patients unless they have hypoglycemia. For patients with acute ischemic or hemorrhagic stroke, normal saline (0.9% sodium chloride) is the preferred intravenous fluid rather than dextrose-containing solutions. If a patient has documented hypoglycemia (blood glucose <60 mg/dL or 3.3 mmol/L), then dextrose administration is appropriate, typically as D50W (50% dextrose in water) at a dose of 25-50 mL IV. The rationale for avoiding dextrose is that hyperglycemia can worsen neurological outcomes in stroke by increasing cerebral lactate production, enhancing free radical formation, and exacerbating tissue acidosis in the ischemic penumbra, as supported by the guidelines for the early management of patients with acute ischemic stroke 1.

Some key points to consider in the management of glucose levels in stroke patients include:

• Maintaining blood glucose levels between 140-180 mg/dL (7.8-10 mmol/L) to avoid hyperglycemia and hypoglycemia, as recommended by the American Diabetes Association and supported by studies such as the NICE-SUGAR study 1.
• Initiating insulin therapy for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL, with a target glucose range of 140 to 180 mg/dL for the majority of critically ill patients, including those with diabetes mellitus 1.
• Monitoring glucose levels regularly and performing ongoing assessments to evaluate the response to glucose management, including changes in the trajectory of glucose levels, intake and output, nutritional status, illness/infection, renal function, and neurological function (cognitive status) 1.

Overall, the goal is to maintain optimal glucose levels to improve outcomes in stroke patients, while avoiding the risks associated with hyperglycemia and hypoglycemia. The most recent and highest quality study, the SHINE trial, is currently being analyzed to assess the targeted glucose concentration that would be safe and result in improved 3-month poststroke outcome 1.

From the FDA Drug Label

A concentrated dextrose solution should not be used when intracranial or intraspinal hemorrhage is present, nor in the presence of delirium tremens if the patient is already dehydrated.

The FDA drug label does not explicitly state that dextrose infusion is contraindicated in patients with stroke. However, it does mention that it should not be used in the presence of intracranial hemorrhage, which can be a type of stroke.

• The label does not provide a direct answer to the question regarding stroke in general.
• It only addresses intracranial hemorrhage, which is a specific condition that may or may not be related to the patient's stroke.
• Therefore, based on the available information, no conclusion can be drawn regarding the use of dextrose infusion in patients with stroke 2.

From the Research

Dextrose Infusion in Patients with Stroke

• The provided studies do not directly address whether dextrose (glucose) infusion is contraindicated in patients with stroke 3, 4, 5, 6, 7.
• However, the studies suggest that hyperglycemia is common in patients with acute ischemic stroke and may have a deleterious effect on outcomes 3, 5.
• The management of hyperglycemia in acute ischemic stroke is challenging, and there is no clear evidence that correcting hyperglycemia leads to better functional outcomes 3, 7.
• Some studies suggest that intensive glucose control with insulin may increase the risk of hypoglycemia, which can also be harmful 6, 7.
• The American Diabetes Association inpatient glycemic control guidelines recommend initiating therapy to achieve glucose targets of 140 to 180 mg/dL in patients with acute ischemic stroke 3.
• Continuous glucose monitoring systems may be useful in managing hyperglycemia in patients with acute stroke 4, 5.

Key Findings

• Hyperglycemia is common in patients with acute ischemic stroke and may worsen outcomes 3, 5.
• Intensive glucose control with insulin may increase the risk of hypoglycemia 6, 7.
• There is no clear evidence that correcting hyperglycemia leads to better functional outcomes in patients with acute ischemic stroke 3, 7.
• The American Diabetes Association inpatient glycemic control guidelines recommend glucose targets of 140 to 180 mg/dL in patients with acute ischemic stroke 3.

Glucose Management

• Patients with acute ischemic stroke should be managed according to the American Diabetes Association inpatient glycemic control guidelines 3.
• Continuous glucose monitoring systems may be useful in managing hyperglycemia in patients with acute stroke 4, 5.
• Caution and close glucose monitoring are necessary, especially for patients prone to hypoglycemia 3, 7.