What is the recommended rate and duration of D5 (dextrose 5%) infusion for perioperative hypoglycemia (blood glucose below 70 mg/dL)?

Perioperative D5 Infusion for Hypoglycemia (Glucose <70 mg/dL)

For perioperative hypoglycemia below 70 mg/dL, administer IV glucose immediately, then initiate continuous D10W infusion at 100 mL/kg per 24 hours (approximately 7 mg/kg per minute) in pediatric patients, or use D5W at maintenance rates in adults, continuing until the patient can tolerate oral intake and blood glucose stabilizes above 100 mg/dL. 1

Immediate Correction Protocol

Administer IV glucose immediately when blood glucose falls below 70 mg/dL (3.9 mmol/L), even in the absence of symptoms. 1, 2

• For blood glucose <60 mg/dL (3.3 mmol/L): Give 15-20 grams of IV dextrose immediately 1
• For blood glucose 60-70 mg/dL with symptoms: Give 15-20 grams of IV dextrose 1
• In unconscious or NPO surgical patients: IV glucose is mandatory regardless of symptoms 2

Bolus Dosing Options:

• D50W: 0.5-1.0 g/kg (1-2 mL/kg), though this causes significant vein irritation and should be diluted to D25W when possible 1
• D25W: 0.5-1.0 g/kg (2-4 mL/kg) - preferred concentration to minimize vein irritation 1
• D10W: 200 mg/kg (2 mL/kg) for initial bolus 1

The median blood glucose response to D50W is approximately 4 mg/dL per gram of dextrose administered, meaning 25 grams typically raises glucose by 100 mg/dL. 3 However, this response is lower in patients with recurrent hypoglycemia and higher in diabetic patients. 3

Continuous Infusion Protocol

After initial correction, immediately start continuous dextrose infusion to prevent recurrent hypoglycemia:

Pediatric Patients:

• D10W at 100 mL/kg per 24 hours (7 mg/kg per minute) with appropriate maintenance electrolytes 1
• Titrate rate to achieve normoglycemia, as hyperglycemia has adverse CNS effects 1
• Older children may require substantially lower doses 1

Adult Patients:

• D5W or D10W at standard maintenance fluid rates (typically 75-125 mL/hour depending on patient size) 1, 2
• Monitor blood glucose every 1-2 hours while NPO and adjust infusion rate accordingly 2
• Target perioperative glucose range: 80-180 mg/dL (4.4-10.0 mmol/L) 1

Duration of Therapy

Continue dextrose infusion until ALL of the following criteria are met:

1. Blood glucose remains stable ≤180 mg/dL (10 mmol/L) for at least 24 hours 1
2. Patient resumes oral feeding 1
3. Underlying cause of hypoglycemia is addressed (e.g., insulin infusion stopped or adjusted, patient eating) 1

Do not abruptly discontinue dextrose infusion, as this leads to rebound hypoglycemia, especially in patients on insulin. 2

Monitoring Requirements

Check blood glucose at the following intervals:

• Every 15 minutes until glucose >100 mg/dL after initial correction 1
• Every 1-2 hours while NPO and receiving dextrose infusion 1, 2
• Every 2-4 hours once stable and tolerating oral intake 1

Monitor for hypoglycemia recurrence: 84% of patients with severe hypoglycemia (<40 mg/dL) had a preceding episode of hypoglycemia (<70 mg/dL) during the same admission, indicating high risk of recurrence. 1

Critical Pitfalls to Avoid

Never delay emergency surgery to "optimize" blood sugar—correct the hypoglycemia with IV glucose and proceed. 2

• Avoid D50W alone without follow-up infusion: Hypoglycemia may recur depending on etiology, particularly with ongoing insulin effect 1
• Do not use sliding scale insulin alone perioperatively: This approach is strongly discouraged and increases hypoglycemia risk 1
• Watch for overcorrection: Administration of D50W per protocol results in hyperglycemia (>150 mg/dL) in 6.8% of cases 3
• Recognize that 75% of patients with hypoglycemia do not have their basal insulin adjusted before the next dose, perpetuating the problem 1

Special Considerations

In patients receiving IV insulin infusion concurrently:

• The blood glucose response to dextrose increases with increasing insulin infusion rate 3
• Consider reducing or temporarily stopping insulin infusion while correcting hypoglycemia 2
• Ensure adequate overlap (1-2 hours) when transitioning from IV insulin to subcutaneous insulin to prevent rebound hyperglycemia 2

Hypoglycemia risk peaks between midnight and 6:00 AM in hospitalized patients on basal insulin. 1 Adjust evening dextrose infusion rates accordingly and ensure more frequent overnight monitoring.

D10W infusion appears at least as effective as D50W bolus in preventing recurrent hypoglycemia and may be preferred during ongoing D50W shortages. 4