What is the treatment for severe hypoglycemia using D50 (50% dextrose solution)?

Treatment of Severe Hypoglycemia with D50

For severe hypoglycemia, administer 10-20 grams of 50% dextrose (D50) intravenously—equivalent to 20-40 mL—titrated based on the initial glucose value, rather than the traditional 25-gram bolus, to avoid dangerous overcorrection while achieving rapid symptom resolution. 1, 2

Dosing Protocol

Initial Administration

• Administer 5-gram aliquots (10 mL of D50) intravenously over 1 minute, repeating every 1-2 minutes until symptoms resolve or blood glucose exceeds 70 mg/dL. 3, 1
• The maximum total dose should not exceed 25 grams to prevent overcorrection. 4
• Stop any insulin infusion immediately when treating hypoglycemia to prevent recurrence. 4

Titration Formula

• A calculated approach can guide dosing: 50% dextrose dose in grams = [100 − blood glucose] × 0.2 grams, which corrects blood glucose into target range in 98% of patients within 30 minutes. 1

Monitoring Requirements

Immediate Monitoring

• Check blood glucose before initial administration. 2
• Recheck blood glucose 15 minutes after treatment, with repeat treatment if blood glucose remains below 70 mg/dL. 4, 1
• Monitor blood glucose every 1-2 hours during any insulin infusion to detect recurrent hypoglycemia. 4, 1

Administration Technique

• For peripheral vein administration, inject slowly through a small-bore needle into a large vein to minimize venous irritation and thrombosis risk. 1
• Concentrated dextrose solutions requiring sustained infusion need central venous access. 1

Critical Safety Considerations

Overcorrection Risks

• Traditional 25-gram D50 boluses produce variable glucose increases of 162 ± 31 mg/dL at 5 minutes in non-diabetic volunteers, frequently causing dangerous overcorrection. 4, 3
• Rapid or repeated D50 boluses have been associated with cardiac arrest and hyperkalemia. 1
• Severe hypoglycemia is independently associated with higher mortality risk (OR 3.233,95% CI [2.251,4.644]). 4, 1

Special Populations

• For neurologic injury patients, treat blood glucose below 100 mg/dL rather than the standard 70 mg/dL threshold. 4, 1
• Avoid hypotonic dextrose solutions in acute ischemic stroke patients, as they can exacerbate cerebral edema; use isotonic solutions instead. 4, 3

Alternative Approaches

D10 as Preferred Alternative

• Emerging evidence suggests that 10% dextrose (D10) administered as 5-gram aliquots (50 mL) may be superior to D50, with fewer adverse events (0/1057 vs 13/310), lower post-treatment glucose levels (6.2 mmol/L vs 8.5 mmol/L), and similar symptom resolution rates (95.9% vs 88.8%). 5, 6
• D10 requires approximately 4 minutes longer for symptom resolution but results in fewer hyperglycemic episodes. 5
• The need for subsequent doses is higher with D10 (19.5%) compared to D50 (8.1%), but total dextrose administered is lower (median 10g vs 25g). 5, 6

When IV Access Unavailable

• For unconscious patients without IV access, use intramuscular glucagon 1 mg, though it takes longer to work (5-15 minutes) and may cause nausea. 4
• Do not give oral or IV dextrose to patients who are unconscious or unable to protect their airway. 4

Common Pitfalls to Avoid

• Never administer the full 25-gram bolus reflexively—this causes excessive hyperglycemia and is associated with worse outcomes. 4, 3
• Do not forget to stop insulin infusions immediately, as failure to do so leads to recurrent hypoglycemia. 4
• Avoid using hypotonic dextrose solutions in stroke patients or those with neurologic injury. 4, 3
• Do not delay treatment waiting for laboratory confirmation in emergency situations—administer dextrose promptly based on clinical presentation and point-of-care glucose testing. 2