Is it recommended to use D5 (Dextrose 5%) containing IV fluids such as D5LR (Dextrose 5% in Lactated Ringer's) or D5NSS (Dextrose 5% in Normal Saline Solution) for a patient with poor intake?

Should You Give D5-Containing IV Fluids for Poor Intake?

No, you should not routinely give D5-containing IV fluids (D5LR or D5NSS) to patients with poor intake unless they have specific indications such as prolonged fasting (>4 hours), inability to self-regulate fluid intake (infants, cognitive impairment), or documented hypoglycemia risk.

Clinical Context and Decision Framework

When D5-Containing Fluids ARE Indicated

Prolonged fasting situations:

• For patients who cannot self-regulate fluid intake and must fast for >4 hours (e.g., pre-anesthesia), 5% dextrose in water at usual maintenance rate is a reasonable initial approach 1
• This provides no renal osmotic load, so urine volume typically decreases considerably 1
• Regular blood glucose monitoring is essential as glucose infusion can lead to hyperglycemia with subsequent osmotic diuresis 1

Pediatric patients at hypoglycemia risk:

• Infants dependent on IV fluids benefit from D10 normal saline to meet glucose requirements of 4-6 mg/kg/min 2, 3
• For newborns, slightly higher glucose requirements of 6-8 mg/kg/min may be necessary 3
• Pediatric patients should receive 2-3 L/m²/d of one quarter normal saline/5% dextrose when unable to take oral intake 1

Specific disease states:

• In diabetic ketoacidosis, switch to D5 or D10 with 0.45-0.75% NaCl when serum glucose reaches 250 mg/dL 2, 3
• For hypernatremic dehydration, 5% dextrose in water is preferred as it prevents worsening hypernatremia 2

When D5-Containing Fluids Should Be AVOIDED

General adult patients with poor intake:

• Non-diabetic adults undergoing elective surgery with average fasting times of almost 13 hours do not develop hypoglycemia and do not require dextrose-containing fluids 4
• Even 500 mL of D5 normal saline causes significant hyperglycemia (plasma glucose 11.1 mmol/L) in 72% of non-diabetic patients 4

Critical care and resuscitation scenarios:

• D5-containing fluids should be avoided in cardiac arrest resuscitation, as they greatly increase morbidity and mortality compared to lactated Ringer's alone 5
• In neurosurgical patients, hypotonic solutions (including those with dextrose) should be avoided to prevent cerebral edema 1
• For traumatic brain injury, 0.9% saline is recommended as first-line therapy, not dextrose-containing solutions 1

Drug diluent considerations:

• Using saline instead of D5W as a drug diluent increases hypernatremia (27.3% vs 14.6%) and hyperchloremia (36.9% vs 20.4%) but has no effect on blood glucose control, AKI, or mortality 6

Practical Algorithm for Poor Intake

Step 1: Assess fasting duration and patient category

• If fasting <4 hours AND able to self-regulate intake → Use non-dextrose crystalloids (normal saline, lactated Ringer's) 1, 4
• If fasting >4 hours AND unable to self-regulate (infant, cognitive impairment) → Consider D5 water at maintenance rate 1

Step 2: Check for hypoglycemia risk factors

• Pediatric patient dependent on IV fluids → Use D10 normal saline 2, 3
• Adult with documented hypoglycemia → Treat hypoglycemia directly with D10 or D50, then reassess need for maintenance dextrose 7
• No hypoglycemia risk → Use non-dextrose crystalloids 4

Step 3: Monitor appropriately if dextrose is used

• Check blood glucose hourly during acute resuscitation, then every 2-4 hours once stable 2
• Monitor for hyperglycemia (>10 mmol/L or 180 mg/dL) which occurs in 72% of patients receiving D5 solutions 4
• Assess for osmotic diuresis if hyperglycemia develops 1

Critical Pitfalls to Avoid

Routine use in adults with poor intake:

• The default assumption that "poor intake = need for dextrose" is incorrect for most adult patients 4
• Adults tolerate prolonged fasting without developing hypoglycemia unless specific risk factors exist 4

Excessive dextrose administration:

• D5-containing fluids provide 50 grams of dextrose per liter, which frequently causes hyperglycemia even in non-diabetic patients 8, 4
• This hyperglycemia can worsen outcomes in critical illness and neurological injury 1, 5

Ignoring sodium and osmolality effects:

• D5 solutions can contribute to hyponatremia and cerebral edema in vulnerable populations 1
• In neurosurgical patients, maintaining normal plasma osmolarity is crucial, making dextrose-containing hypotonic solutions particularly dangerous 1