What is the recommended initial dose and administration guidelines for a continuous infusion of glucose 40% in a 70-kilogram patient with hypoglycemia?

Continuous Glucose 40% Infusion for Hypoglycemia

For a 70-kg patient with hypoglycemia requiring continuous IV glucose, administer dextrose in 5-10 gram aliquots (12.5-25 mL of 40% dextrose) every minute until symptoms resolve or blood glucose exceeds 70 mg/dL, with a maximum initial total dose of 25 grams (62.5 mL), then transition to a maintenance infusion of 5-10% dextrose at rates sufficient to maintain glucose 100-180 mg/dL. 1

Initial Bolus Treatment

• Administer 10-20 grams of IV dextrose immediately for unconscious patients or those unable to swallow, which translates to 25-50 mL of 40% dextrose solution 1, 2
• Give the dextrose in divided aliquots of 5-10 grams (12.5-25 mL of 40% solution) repeated every minute rather than as a single large bolus 1
• Check capillary blood glucose before the first dose and recheck at 15 minutes post-treatment 1, 3
• Continue repeating 5-10 gram doses until blood glucose exceeds 70 mg/dL or symptoms resolve, not exceeding 25 grams total in the initial treatment phase 1

Critical Monitoring During Treatment

• Stop any concurrent insulin infusion immediately when treating hypoglycemia to prevent recurrence 1
• Recheck blood glucose every 15 minutes after each treatment dose until glucose stabilizes above 70 mg/dL 1, 2
• If on continuous insulin infusion, monitor glucose every 1-2 hours after stabilization 1
• For patients with neurologic injury, treat at a higher threshold of <100 mg/dL rather than the standard <70 mg/dL 1

Transition to Maintenance Infusion

After initial correction with 40% dextrose boluses, you cannot continue 40% dextrose as a continuous infusion due to vein sclerosis risk. Instead:

• Transition to 5-10% dextrose continuous infusion at rates of 100-150 mL/hour (5-15 grams glucose/hour) to maintain glucose in target range 4
• The maximum glucose oxidation rate is 4-7 mg/kg/min (approximately 400-700 g/day for a 70-kg patient), so infusion rates should not exceed 5 mg/kg/min to avoid metabolic complications 4
• Target maintenance glucose of 100-180 mg/dL for most patients, or 140-180 mg/dL if critically ill 4

Common Pitfalls to Avoid

• Never use 40% dextrose as a continuous infusion—it causes severe vein sclerosis and thrombophlebitis; use only for bolus correction 1
• Do not administer oral glucose to unconscious patients—this risks aspiration and airway compromise 1, 2
• Avoid 5% dextrose solutions in acute stroke patients as they worsen cerebral edema; use isotonic solutions instead 1
• Do not rely on sliding-scale insulin alone after glucose correction, as this approach is strongly discouraged and leads to recurrent hyper- and hypoglycemia 4, 1

Post-Treatment Protocol

• Once glucose normalizes and symptoms resolve, provide starchy or protein-rich foods if more than 1 hour until the next meal 1
• Any severe hypoglycemic episode requiring IV dextrose mandates complete reevaluation of the diabetes management plan 1, 2
• Investigate precipitating factors including inappropriate insulin timing, reduced oral intake, interruption of nutrition (enteral/parenteral), or sudden reduction in corticosteroid dose 1
• Document all hypoglycemic episodes in the medical record to identify patterns and prevent recurrence 1

Adjusting Concurrent Insulin Therapy

• If the patient was on basal insulin, reduce the dose by 20-40% after a hypoglycemic event requiring IV dextrose 1
• For NPO patients, use basal insulin at 60-80% of usual dose plus correction doses only—never sliding-scale insulin alone 1
• When transitioning from IV insulin infusion, give subcutaneous basal insulin at 60-80% of the 24-hour IV insulin dose, administered 1-2 hours before stopping the infusion 4