D5W is NOT the appropriate treatment for hypoglycemia
D5W (5% dextrose in water) should not be used to treat hypoglycemia because it contains insufficient dextrose concentration to rapidly correct dangerously low blood glucose levels. The standard treatment requires higher concentrations of dextrose (10%, 25%, or 50%) administered as boluses, not continuous infusions of dilute dextrose solutions.
Treatment Approach Based on Patient Status
For Conscious Patients Who Can Swallow
- Oral glucose is the first-line treatment 1
- Administer 15-20 grams of oral glucose (tablets preferred over gel or dietary sources) 1
- Glucose tablets demonstrate superior symptom resolution at 15 minutes compared to dietary sugars 1
- Reassess in 10 minutes; activate EMS if no improvement 1
For Unconscious or Unable-to-Swallow Patients
Intravenous dextrose is lifesaving and mandatory 1. The concentration matters significantly:
Recommended IV Dextrose Concentrations:
- D10W (10% dextrose) is now preferred over D50W for most adult hypoglycemia treatment 2, 3, 4
- Administer 5-gram aliquots (50 mL of D10W) repeated every 1 minute until Glasgow Coma Scale reaches 15 5, 2
- Median total dose required: 10 grams with D10W versus 25 grams with D50W 5, 2
- Time to recovery is comparable: approximately 6-8 minutes for both concentrations 5, 2, 4
Why D10W Over D50W:
- Lower post-treatment blood glucose levels (6.2 mmol/L vs 9.4 mmol/L), reducing rebound hyperglycemia 2, 4
- Fewer adverse events: 0% with D10W versus 4.2% with D50W 3
- Less risk of extravasation injury due to lower osmolarity 2
- Nearly identical efficacy: 99.2% resolution with D10W versus 98.7% with D50W 3
Alternative Concentrations:
- D25W: 5-gram aliquots (20 mL) are reasonable alternatives 5
- D50W: Traditional 25-gram bolus (50 mL of 50% dextrose) remains acceptable but causes excessive hyperglycemia 1, 6
Pediatric Considerations
- D10W is the preferred concentration for children 1
- Dose: 200 mg/kg (2 mL/kg of D10W) 1
- For hypoglycemia with altered consciousness: 0.5-1.0 g/kg dextrose 1
- D50W should be diluted to D25W in children due to vein irritation 1
- Constant infusion rate if needed: 100 mL/kg per 24 hours of D10W (7 mg/kg per minute) 1
Critical Pitfalls to Avoid
Why D5W Fails as Treatment:
- D5W contains only 5 grams of dextrose per 100 mL - far too dilute for acute correction 1
- D5W is used for maintenance fluid therapy to prevent hypoglycemia, not to treat established hypoglycemia 1
- In cerebral malaria protocols, D5W with half-normal saline prevents hypoglycemia during fluid resuscitation but requires separate bolus treatment (50 mL of 50% dextrose) when hypoglycemia occurs 1
Monitoring Requirements:
- Check blood glucose every 1-2 hours during insulin infusions to prevent recurrent hypoglycemia 1
- Blood glucose should be monitored 60 minutes after initial treatment as additional doses may be necessary 1
- Hypoglycemia may recur depending on etiology, particularly with long-acting insulin or sulfonylureas 1
Adjunctive Therapy:
- Glucagon 1 mg IM/IV is an alternative when IV access unavailable 1, 6
- Glucagon has slower onset (recovery in 6.5 minutes vs 4.0 minutes with dextrose) and is less preferred when IV access exists 6
- For insulin-induced hypoglycemia: glucagon 0.03 mg/kg (maximum 1 mg) can be repeated every 15 minutes up to 3 doses 1
Special Clinical Contexts
ICU/Hospital Settings:
- Basal-bolus insulin regimens carry 4-6 times higher hypoglycemia risk than sliding scale alone 1
- Titrated dextrose replacement prevents overcorrection: administer 10-20 grams IV dextrose based on formula (100 - blood glucose) × 0.2 grams 1
- Avoid targeting euglycemia (80-110 mg/dL) in critically ill patients due to excessive hypoglycemia risk 1