D5LR Should Be Avoided in Stroke Patients
D5LR (5% dextrose in lactated Ringer's solution) is contraindicated in acute stroke patients and should never be used. The American Heart Association explicitly recommends avoiding intravenous solutions containing glucose in acute stroke management 1.
Why D5LR Is Harmful in Stroke
Dextrose Component Worsens Outcomes
- Hyperglycemia exacerbates brain injury through multiple mechanisms: increased cerebral edema, higher risk of hemorrhagic transformation, lower likelihood of recanalization, and deteriorating neurological status 1, 2, 3.
- Glucose-containing IV fluids worsen hyperglycemia, which is already present in >40% of acute stroke patients 4.
- Even in non-diabetic patients, post-stroke hyperglycemia occurs as a stress response and correlates with worse functional outcomes and increased mortality 2, 5.
Lactated Ringer's Is Hypotonic
- Lactated Ringer's solution should be avoided in acute hemorrhagic stroke because it is hypotonic and can exacerbate cerebral edema 1.
- Hypotonic solutions distribute unevenly and worsen intracranial pressure in the setting of acute brain injury 1.
Correct Fluid Management in Stroke
Use Normal Saline Only
- Isotonic saline (0.9% NaCl) is the only recommended maintenance fluid for acute stroke patients, as it distributes uniformly in extracellular spaces without worsening cerebral edema 1, 6.
- Administer at 30 mL/kg body weight per day to maintain euvolemia and preserve cerebral perfusion 1.
Avoid All Glucose-Containing Solutions
- Solutions to avoid include: D5W, D5LR, D5NS, 0.45% saline, and colloids 1, 6.
- The only exception is emergency hypoglycemia correction (glucose <60 mg/dL), which requires 25 mL of 50% dextrose as a slow IV bolus 4, 6.
Managing Hyperglycemia in Stroke Patients
Target Glucose Range
- Maintain blood glucose between 140-180 mg/dL using insulin therapy, per American Heart Association/American Stroke Association guidelines 4, 6.
- This target balances the harm of hyperglycemia against the risk of hypoglycemia, which can cause permanent brain damage 4, 6.
Evidence Against Intensive Glucose Control
- The SHINE trial (2019) definitively showed that intensive glucose control (target 80-130 mg/dL) provided no benefit over standard control (80-179 mg/dL) and caused significantly more severe hypoglycemia (2.6% vs 0%) 7.
- Aggressive insulin therapy increases hypoglycemia risk without improving functional outcomes 2, 7.
Monitoring Requirements
- Check blood glucose immediately on presentation via finger stick 6.
- Monitor glucose every 1-2 hours initially, especially if thrombolysis is administered 6, 8.
- Use continuous IV insulin infusion for severe hyperglycemia (>1000 mg/dL), starting at 0.5 units/hour and titrating to maintain 140-180 mg/dL 8.
Special Considerations for Diabetic Stroke Patients
Higher Glucose Thresholds
- In diabetic patients with ischemic stroke, the cut-off glucose level predicting death is >210.5 mg/dL, compared to >113.5 mg/dL in non-diabetics 5.
- Diabetic patients have shifted thresholds for hypoglycemic symptoms, with brain dysfunction potentially occurring at higher glucose levels 4.
Avoid Hypoglycemia at All Costs
- Hypoglycemia can mimic stroke symptoms and cause permanent brain damage if untreated 4, 6.
- The risk of hypoglycemia from aggressive insulin therapy outweighs potential benefits of tight glucose control 2, 7.
Critical Pitfalls to Avoid
- Never use D5LR or any glucose-containing maintenance fluids in stroke patients—this directly contradicts AHA guidelines 1, 6.
- Do not target glucose <140 mg/dL—this increases hypoglycemia risk without proven benefit 6, 8, 7.
- Do not delay stroke evaluation in hyperglycemic patients—both conditions may coexist and require simultaneous management 8.
- Do not assume hyperglycemia is purely metabolic—proceed with full stroke workup including brain imaging 8.
- Do not use subcutaneous insulin alone for severe hyperglycemia (>1000 mg/dL)—IV insulin is mandatory for rapid, titratable control 8.