Do we start with D5 (5% dextrose solution) or D50 (50% dextrose solution) for hypoglycemia?

Management of Hypoglycemia: D50 vs D5 Selection

For severe hypoglycemia requiring IV treatment, D50 (50% dextrose) should be used as first-line therapy in adults, while D10 or D25 is preferred in pediatric patients due to safety considerations.

Adult Hypoglycemia Management

Conscious Patients

• For conscious patients who can swallow:
  • Administer 15-20g of oral glucose (glucose tablets preferred) 1
  • Recheck blood glucose after 15 minutes
  • If blood glucose remains <3.9 mmol/L (70 mg/dL), repeat oral glucose
  • Once blood glucose >3.9 mmol/L, provide starchy or protein-rich food if next meal is >1 hour away 1

Unconscious or Unable to Swallow

• For unconscious patients or those unable to swallow:
  • Administer 50% dextrose (D50): 10-25g IV (20-50 mL) 2
  • For adults with insulin-induced hypoglycemia, 10-25g of dextrose (20-50 mL of D50) is typically adequate 2
  • If blood glucose remains <3.0 mmol/L after initial treatment, administer 60 mL of 50% glucose solution IV 1

Pediatric Hypoglycemia Management

• D50 is irritating to veins; dilution to D25 or D10 is preferred in pediatric patients 1
• Dosing recommendations:
  • D10W: 2 mL/kg (200 mg/kg)
  • D25W: 2-4 mL/kg (0.5-1.0 g/kg)
  • D50W: 1-2 mL/kg (0.5-1.0 g/kg) - only if diluted options unavailable 1

Concentration Selection Considerations

Advantages of D50

• Faster resolution of symptoms (median 4.1 minutes vs 8.0 minutes for D10) 3
• Lower need for subsequent doses (8.1% vs 19.5% for D10) 3
• Smaller volume of fluid administration

Advantages of D10

• Fewer adverse events (0/1057 vs 13/310 for D50) 3
• Lower post-treatment blood glucose (6.2 mmol/L vs 8.5 mmol/L for D50) 3
• May reduce risk of rebound hyperglycemia
• Less irritating to veins if extravasation occurs

Recent Evidence

A 2024 randomized controlled study found no difference in the median time to achieve normal mental status (GCS 15) between 10%, 25%, and 50% dextrose solutions (all approximately 6 minutes) 4. However, the total median dose administered in the 10% and 25% groups was lower than in the 50% group (10g vs 15g) 4.

Post-Treatment Monitoring

• Monitor blood glucose every 15 minutes until stable
• Investigate the cause of hypoglycemia and adjust medications as needed
• Consider relaxing glucose control targets temporarily in patients who experienced cognitive impairment 1
• Activate EMS if hypoglycemia doesn't improve within 10 minutes of treatment 1

Important Caveats

• Never administer oral glucose to patients who are not awake or unable to swallow 1
• D50 may cause extravasation injury and potential neurotoxic effects of hyperglycemia 5
• The median effect of D50W on blood glucose is approximately 4 mg/dL per gram administered 6
• Patients with diabetes may have a higher blood glucose response to dextrose, while those with recurrent hypoglycemia may have a lower response 6

In summary, while both D5 and D50 can effectively treat hypoglycemia, D50 is preferred for adults with severe hypoglycemia requiring IV treatment due to faster symptom resolution, while D10 or D25 is safer for pediatric patients.