Can we administer D25 (50% dextrose solution) infusion in an adrenal crisis?

Management of D25 Infusion in Adrenal Crisis

D25 (25% dextrose) infusion can be administered during an adrenal crisis, especially when hypoglycemia is present, but should be given alongside the essential treatments of hydrocortisone and isotonic saline.

Primary Treatment for Adrenal Crisis

The cornerstone management of adrenal crisis involves:

1. Immediate Hydrocortisone Administration

   • Give 100 mg IV hydrocortisone bolus immediately 1
   • Follow with 100-300 mg/day as continuous infusion or divided doses every 6 hours 1
   • Do not delay treatment for diagnostic procedures 1

2. Fluid Resuscitation

   • Administer 3-4 L of isotonic saline (0.9% NaCl) 1
   • Initial infusion rate of approximately 1 L/hour 1
   • Continue IV fluids at a slower rate for 24-48 hours 1

Role of Dextrose in Adrenal Crisis

Hypoglycemia is a common feature in adrenal crisis, particularly in children 1. When hypoglycemia is present:

• For hypoglycemia management:

  • D25W can be administered at 2-4 mL/kg (equivalent to 0.5-1.0 g/kg) 1
  • Consider using D10W-containing IV fluids with appropriate electrolytes at 100 mL/kg per 24 hours for maintenance 1

• Important considerations:

  • D25W is less irritating to veins than D50W but more concentrated than D10W 1
  • Monitor glucose, sodium, and potassium levels carefully 1
  • Titrate dextrose administration to achieve normoglycemia without causing hyperglycemia 1

Special Considerations

1. For pediatric patients:

   • Strongly consider concomitant fluid bolus of 20 mL/kg of D5NS or D10NS during the first hour of treatment for adrenal insufficiency 1
   • Monitor for signs of fluid overload (increased work of breathing, rales, gallop rhythm, hepatomegaly) 1

2. For monitoring:

   • Check blood glucose levels every 1-2 hours initially 2
   • Monitor serum electrolytes regularly 2
   • Avoid rapid administration of concentrated dextrose solutions due to risk of cardiac complications 2

Potential Pitfalls

1. Do not delay hydrocortisone administration while preparing dextrose solutions - hydrocortisone is the life-saving intervention 3

2. Avoid overcorrection of hypoglycemia which can lead to iatrogenic hyperglycemia 1

3. Do not rely solely on dextrose infusion without addressing the underlying cortisol deficiency and fluid/electrolyte imbalances 4

4. Be aware that hypoglycemia may recur depending on etiology, requiring ongoing monitoring 1

5. Remember that infections are the major precipitating cause of adrenal crisis and should be identified and treated 5

By following these guidelines, D25 infusion can be safely administered as part of comprehensive management of adrenal crisis when hypoglycemia is present, while ensuring the primary treatments of hydrocortisone and fluid resuscitation are prioritized.