What are the appropriate routes and doses of dextrose for treating hypoglycemia in conscious versus unconscious patients, including pediatric weight‑based dosing?

How to Administer Dextrose in Hypoglycemia

Conscious Patients Who Can Swallow

For conscious adults and children who can swallow, administer 15–20 grams of oral glucose tablets as first-line treatment; chew and swallow the tablets immediately rather than using buccal or sublingual routes. 1, 2

• Pure glucose tablets produce the most rapid and predictable glycemic response, raising blood glucose approximately 40 mg/dL with 10 grams or 60 mg/dL with 20 grams over 30–45 minutes. 2
• Recheck blood glucose at 15 minutes; if still below 70 mg/dL, repeat the 15–20 gram dose. 2
• Avoid buccal administration in patients who can swallow—buccal glucose results in lower plasma glucose concentrations at 20 minutes compared to swallowed glucose. 1, 2
• If glucose tablets are unavailable, use 15 grams of glucose dissolved in 150 mL of water as an equivalent alternative. 2

Pediatric-Specific Oral Treatment

• For conscious children who can swallow, prioritize oral/swallowed glucose tablets or solution as the gold standard. 3
• For uncooperative children who refuse to swallow but remain conscious, use sublingual glucose administration (granulated sugar slurry under the tongue). 3
• 40% dextrose gel (200 mg/kg as a single dose) massaged into the buccal mucosa is an acceptable alternative when tablets are unavailable or the child is uncooperative. 3

Unconscious or Unable-to-Swallow Patients

For unconscious patients or those unable to protect their airway, never give oral glucose; instead, administer intravenous dextrose 10% in 5-gram aliquots (50 mL) over 1 minute, repeating every minute until symptoms resolve or blood glucose exceeds 70 mg/dL, with a maximum total dose of 25 grams. 4

IV Dextrose Administration Protocol

• Use 10% dextrose concentration rather than 50% dextrose—it achieves equivalent symptom resolution (95.9% vs 88.8%) with significantly fewer adverse events (0% vs 4.2%) and lower post-treatment hyperglycemia (6.2 mmol/L vs 9.4 mmol/L). 5, 6
• Administer 5-gram aliquots over 1 minute, repeating every minute as needed. 4, 7
• Median time to achieve Glasgow Coma Scale of 15 is 6–8 minutes with 10% dextrose versus 4 minutes with 50% dextrose, but the slightly longer time is offset by superior safety profile. 5, 7, 6
• Stop any insulin infusion immediately when treating hypoglycemia to prevent recurrence. 4

Dosing Strategy to Avoid Overcorrection

• Titrate the dose based on initial hypoglycemic value—a 25-gram bolus of dextrose produces variable increases of 162 ± 31 mg/dL at 5 minutes in non-diabetic volunteers, frequently causing overcorrection. 4
• The median total dose required with 10% dextrose is 10 grams versus 15–25 grams with 50% dextrose. 7, 6
• Expect approximately 4 mg/dL rise per gram of dextrose administered, though this varies with diabetes status, insulin infusion rate, and recurrent hypoglycemia. 8

Monitoring Requirements

• Check blood glucose before initial administration and recheck 15 minutes after treatment. 4
• If blood glucose remains below 70 mg/dL at 15 minutes, repeat treatment. 4
• Monitor blood glucose every 1–2 hours during any insulin infusion to detect recurrent hypoglycemia. 4

Alternative: Intramuscular Glucagon

When IV access is unavailable in unconscious patients, administer intramuscular glucagon 1 mg as a safer alternative, though it takes 5–15 minutes to work and may cause nausea. 4

• Glucagon is effective but slower than IV dextrose—median recovery time is 6.5 minutes versus 4.0 minutes with dextrose. 9
• Glucagon produces a different glycemic profile compared to dextrose but achieves equivalent resolution of hypoglycemic coma. 9

Special Population Considerations

Neurologic Injury Patients

• Treat blood glucose below 100 mg/dL (rather than the standard 70 mg/dL threshold) in patients with neurologic injury. 4
• Avoid hypotonic solutions like 5% dextrose in acute ischemic stroke patients, as they exacerbate cerebral edema; use isotonic solutions instead. 4

Pediatric Emergency Thresholds

• Activate emergency services immediately for any infant unable to swallow, not awake, or seizing. 3
• Avoid repetitive or prolonged hypoglycemia ≤45 mg/dL (2.5 mmol/L) due to risk of permanent neurological injury. 3
• Infants <6 months represent a higher-risk population requiring lower threshold for emergency activation. 3

Diabetes Management Patients

• Use caution in patients with diabetes mellitus, as they may require insulin supplementation to prevent rebound hyperglycemia. 4
• Any severe hypoglycemic episode requiring external assistance mandates complete reevaluation of the diabetes management plan. 2, 3

Critical Pitfalls to Avoid

• Never administer oral glucose to unconscious patients—this creates aspiration risk; use IV dextrose or IM glucagon instead. 4, 2
• Do not add fat to carbohydrate treatment—it retards the acute glycemic response. 2
• Do not add protein to carbohydrate treatment—it does not prevent subsequent hypoglycemia and may increase insulin response in type 2 diabetes. 2
• Avoid 50% dextrose as first-line IV treatment—it causes more overcorrection, higher rates of hyperglycemia, and increased adverse events compared to 10% dextrose. 5, 6
• Severe hypoglycemia is independently associated with higher mortality risk (OR 3.233,95% CI [2.251,4.644]). 4