What is the recommended rate of 10% dextrose infusion in Diabetic Ketoacidosis (DKA) when blood glucose levels fall below 250 mg/dL?

Dextrose Administration Rate in DKA When Glucose Falls Below 250 mg/dL

Direct Recommendation

When blood glucose falls below 250 mg/dL during DKA treatment, switch to 5% dextrose in 0.45-0.75% NaCl (D5W with saline) and continue this infusion at the same rate as your crystalloid replacement fluids, targeting 50% of estimated fluid deficit replacement over the first 8-12 hours. 1, 2

Standard Protocol

Fluid Transition Strategy

• Change from 0.9% NaCl to 5% dextrose with 0.45-0.75% NaCl when glucose reaches 250 mg/dL 1, 2
• Continue the same infusion rate you were using for initial fluid resuscitation (typically aiming to replace 50% of fluid deficit in first 8-12 hours) 1
• Maintain target glucose between 150-200 mg/dL until DKA resolution 1

Alternative Approach for Euglycemic DKA

• If dealing with euglycemic DKA (glucose already <200 mg/dL at presentation), higher dextrose concentrations (10% or 20%) may be required from the outset to facilitate the large insulin doses needed to correct severe acidosis 3
• In these cases, 10% dextrose can be administered at maintenance fluid rates (approximately 100 mL/kg per 24 hours or 7 mg/kg per minute in pediatric patients, with substantially lower rates for adults) 1

Critical Management Points

Insulin Continuation

• Do not stop or reduce insulin infusion when adding dextrose - the goal is to continue clearing ketones while preventing hypoglycemia 1, 2
• Standard insulin infusion rate of 0.05-0.10 units/kg/hour should continue until DKA resolves (pH >7.3, bicarbonate >15 mEq/L, anion gap closure) 1

Monitoring Requirements

• Check blood glucose every 2-4 hours minimum during dextrose infusion 1
• Monitor electrolytes, renal function, venous pH, and osmolality every 2-4 hours until stable 1
• Ensure potassium is maintained between 4-5 mEq/L throughout treatment 1

Common Pitfalls to Avoid

Timing Errors

• Do not delay adding dextrose when glucose reaches 250 mg/dL - this is a common error that can lead to hypoglycemia while trying to clear ketoacidosis 1, 2
• Recent data shows significant delays (median 3.2 hours) between starting dextrose and appropriately adjusting management when glucose falls below target 4

Concentration Confusion

• Standard DKA protocols use 5% dextrose (D5W), not 10% dextrose as the initial dextrose concentration 1, 2
• 10% dextrose is reserved for specific situations: euglycemic DKA, prevention of hypoglycemia during insulin infusions when nutrition is interrupted, or as a continuous infusion for hyperkalemia management 1, 2, 3

Rate Adjustment Mistakes

• The dextrose-containing fluid should run at your standard crystalloid replacement rate - there is no separate "dextrose drip rate" to calculate 1
• If using 10% dextrose for euglycemic DKA or special circumstances, a 250 mL bag over 2 hours has been shown to significantly reduce hypoglycemia risk in vulnerable populations 5

Special Populations

Pediatric Patients

• Same glucose threshold applies: add 5% dextrose to 0.45-0.75% NaCl when glucose reaches 250 mg/dL 2
• If using 10% dextrose for other indications, maintenance rate is approximately 100 mL/kg per 24 hours (7 mg/kg per minute), though older children require substantially lower doses 1

Patients with Impaired Renal Function

• These patients are at higher risk for hypoglycemia and may benefit from earlier dextrose initiation or higher concentrations 5
• Consider 10% dextrose infusion (250 mL over 2 hours) in addition to standard bolus if pre-insulin glucose is ≤250 mg/dL and creatinine clearance <30 mL/min 5