What is the appropriate initial infusion rate and adjustment strategy for 10% dextrose (D10) in a 70 kg adult with acute hepatitis or liver dysfunction, based on glucose monitoring results?

D10 Infusion Rate Strategy for Liver Dysfunction

Start D10 at 50 mL/hour (5 grams/hour) and adjust based on glucose monitoring every 2 hours, targeting blood glucose of 100-150 mg/dL in patients with acute liver failure or hepatic dysfunction. 1, 2

Initial Infusion Rate

• Begin with 50 mL/hour of D10, which delivers 5 grams of dextrose per hour (120 grams over 24 hours) 1, 2
• This rate aligns with physiologic glucose utilization and prevents hypoglycemia while avoiding excessive glucose load 2
• For a 70 kg adult, this provides approximately 1.7 g/kg/day, which is below the threshold associated with hepatic complications 3

Glucose Monitoring Protocol

• Check blood glucose every 2 hours minimum in patients with acute liver failure, as hypoglycemia is a well-known complication that can be confused with hepatic encephalopathy 4
• More frequent monitoring (every 1 hour) may be needed during initial titration or if glucose instability occurs 2
• Clinical features of hypoglycemia overlap with hepatic encephalopathy symptoms, making regular monitoring essential 4

Adjustment Algorithm Based on Glucose Results

If glucose < 70 mg/dL:

• Immediately give 10-20 grams of dextrose as bolus (100-200 mL of D10 or 20-40 mL of D50) 2, 5
• Increase maintenance D10 rate by 25 mL/hour (to 75 mL/hour) 1
• Recheck glucose in 15 minutes, then hourly until stable 2

If glucose 70-100 mg/dL:

• Increase D10 rate by 10-25 mL/hour (to 60-75 mL/hour) 1, 2
• Continue monitoring every 2 hours 4

If glucose 100-150 mg/dL (target range):

• Continue current rate of 50 mL/hour 1, 2
• Monitor every 2 hours 4

If glucose 150-200 mg/dL:

• Decrease D10 rate by 10-25 mL/hour (to 25-40 mL/hour) 1
• Monitor every 2 hours 4

If glucose > 200 mg/dL:

• Consider stopping D10 temporarily and reassess in 1-2 hours 1
• If persistent hyperglycemia, may need insulin coverage while maintaining some dextrose infusion 1

Critical Safety Considerations for Liver Dysfunction

• Avoid dextrose infusion rates > 5 mg/kg/min (approximately 350 mg/min or 21 grams/hour for 70 kg patient), as higher rates are associated with hepatic enzyme elevations 3
• Your proposed rate of 50 mL/hour D10 equals 5 grams/hour or approximately 3.5 mg/kg/min for a 70 kg patient, which is well within safe limits 3
• Target serum sodium 140-145 mmol/L, as hyponatremia correlates with increased intracranial pressure in acute liver failure 4
• Correct sodium abnormalities slowly, not exceeding 10 mmol/L per 24 hours 4

Common Pitfalls to Avoid

• Do not use D50 boluses routinely, as rapid administration of concentrated dextrose has been associated with cardiac arrest and hyperkalemia 2, 5
• Titrate with 5-gram aliquots (50 mL of D10) when treating hypoglycemia rather than giving large boluses, which achieves target glucose in 98% of patients within 30 minutes with less rebound hyperglycemia 2, 6
• Do not delay glucose monitoring - hypoglycemia in liver failure can be rapidly fatal and symptoms overlap with encephalopathy 4
• Avoid overcorrection - post-treatment glucose of 112 mg/dL with titrated D10 is superior to 169 mg/dL seen with traditional D50 boluses 5

Practical Implementation

• A 1000 mL bag of D10 at 50 mL/hour will last 20 hours, so plan for bag changes 1
• D10 can be administered peripherally without the thrombosis risk of higher concentrations 2
• If using D10 for hypoglycemia treatment, 100 mL (10 grams) is effective initial dose with median time to recovery of 8 minutes 6, 7
• Approximately 23% of patients require a second dose when treating acute hypoglycemia with D10 7