Will D10W (10% dextrose in water) and hydrocortisone 50 (hydrocortisone) significantly elevate blood glucose levels in a patient with stress hyperglycemia and no underlying diabetes when off tube feeds?

Management of Hyperglycemia with D10W and Hydrocortisone in a Patient with Stress Hyperglycemia

Yes, the combination of D10W and hydrocortisone 50 mg will significantly elevate blood glucose levels in a patient with stress hyperglycemia, even without underlying diabetes and when off tube feeds. 1

Mechanisms of Hyperglycemia

• Glucocorticoids (hydrocortisone) cause hyperglycemia through increased insulin resistance and enhanced hepatic glucose production, with afternoon and evening hyperglycemia being particularly common 1
• D10W provides 10 g of dextrose per 100 mL, which directly contributes to hyperglycemia, especially when administered intravenously 1
• Stress hyperglycemia itself represents a state of insulin resistance and decreased insulin secretion due to counterregulatory hormone and cytokine responses during critical illness 2

Expected Glycemic Impact

• When hydrocortisone is administered as bolus injections (as opposed to continuous infusion), patients experience significantly more hyperglycemic episodes (15.7 ± 8.5 vs 10.5 ± 8.6 episodes per patient) 3
• Even in patients without diabetes, a single dose of hydrocortisone can cause significant blood glucose elevations 1
• D10W infusion at even moderate rates (50 mL/hr) provides substantial glucose load that can exacerbate hyperglycemia 1

Management Recommendations

Monitoring

• Implement regular capillary glucose measurements (every 4-6 hours) to detect and respond to hyperglycemia 1
• Monitor for hyperglycemia particularly in the afternoon and evening hours when steroid-induced hyperglycemia typically peaks 1

Insulin Management

• For patients receiving hydrocortisone who develop hyperglycemia:
  • Consider a more resistant sliding scale insulin regimen to address steroid-induced insulin resistance 1
  • If persistent hyperglycemia develops, consider adding isophane insulin (NPH) at a dose of 0.1-0.3 units/kg/day 1

D10W Management

• If D10W is being used to prevent hypoglycemia during interruption of tube feeds, consider:
  • Using the minimum effective rate (typically 50 mL/hr is recommended) 1
  • Transitioning to D5W if hyperglycemia becomes significant 1

Special Considerations

• Blood glucose target should be 140-180 mg/dL for most hospitalized patients, avoiding both hyperglycemia and hypoglycemia 1
• Patients with stress hyperglycemia often have worse outcomes than those with known diabetes, making glucose control important 1, 2
• When hydrocortisone therapy is discontinued, insulin requirements can decrease rapidly, requiring prompt adjustment of insulin doses to prevent hypoglycemia 1

Pitfalls to Avoid

• Failing to recognize steroid-induced hyperglycemia due to focus only on fasting glucose levels (steroid effect often peaks in afternoon/evening) 4
• Underestimating the additive hyperglycemic effects when both D10W and steroids are used simultaneously 1
• Continuing the same insulin regimen after hydrocortisone is discontinued, which can lead to hypoglycemia 1
• Using sulfonylureas to manage steroid-induced hyperglycemia (not recommended) 1