Why can't D10 (10% dextrose in water) be used to manage hypernatremia?

Why D10 (10% Dextrose in Water) CAN Be Used for Hypernatremia Management

D10 is actually an appropriate and effective solution for managing hypernatremia because it contains zero sodium (0 mEq/L) and delivers free water after the dextrose is metabolized, making it functionally equivalent to D5W for sodium correction. 1

Mechanism of Action

• D10 contains no sodium (0 mEq/L), just like D5W, consisting solely of dextrose dissolved in sterile water 1
• After infusion, the dextrose is rapidly metabolized, leaving only free water behind with effectively zero tonicity and no renal osmotic load 2
• This free water dilutes serum sodium concentration, making D10 suitable for hypernatremia correction 1

Clinical Applications Where D10 Is Appropriate

Pediatric Populations

• D10 is specifically recommended in pediatric septic shock to provide adequate glucose delivery (4-6 mg/kg/min in infants, 6-8 mg/kg/min in newborns) while maintaining fluid balance 3
• In children with sepsis, using lower glucose concentrations (D5% or lower volumes of D10%) will not meet glucose delivery requirements 3
• D10 serves dual purposes: correcting hypernatremia while preventing hypoglycemia in vulnerable populations 3

Hyperglycemic Crisis with Hypernatremia

• Once serum glucose reaches 250-300 mg/dL in DKA/HHS, fluids should be changed to D5W (or D10W at adjusted rates) with appropriate electrolytes to prevent worsening hypernatremia 2
• The American Diabetes Association recommends 5% dextrose with 0.45-0.75% NaCl and potassium once glucose normalizes 2

Key Differences Between D5W and D10W

The primary difference is glucose concentration, not sodium content:

• D5W provides 5g dextrose/100mL; D10W provides 10g dextrose/100mL 1
• Both contain 0 mEq/L sodium 1
• D10W delivers twice the glucose load, requiring adjustment of infusion rate to achieve the same free water delivery 1

Practical Implementation

Rate Adjustment

• If using D10W instead of D5W, infuse at approximately half the calculated D5W rate to deliver equivalent free water while providing higher glucose concentration 1
• For example: if D5W rate is 127 mL/hour, D10W rate would be approximately 63-65 mL/hour for similar free water delivery

Safety Parameters

• Serum sodium correction must not exceed 8-10 mEq/L per 24 hours to prevent osmotic demyelination syndrome 2, 4
• Monitor serum sodium every 2-4 hours during active correction 2, 4
• Induced change in serum osmolality should not exceed 3 mOsm/kg H₂O per hour 2, 4

Electrolyte Supplementation

• Add 20-30 mEq/L potassium (2/3 KCl and 1/3 KPO4) once adequate urine output (≥0.5 mL/kg/hour) is confirmed and serum potassium <5.5 mEq/L 2, 4

Common Clinical Scenarios Where D10W Is Preferred

Pediatric Patients

• Infants and young children requiring both hypernatremia correction and glucose supplementation benefit from D10W because it meets higher glucose requirements (6-8 mg/kg/min) while providing free water 3

Patients at Risk for Hypoglycemia

• Patients with sepsis, critical illness, or inadequate glycogen stores require higher glucose delivery that D10W provides more efficiently 3

Volume-Restricted Patients

• When fluid overload is a concern (cardiac or renal compromise), D10W delivers the same free water in half the volume compared to D5W 4

Critical Pitfalls to Avoid

• Never use normal saline (0.9% NaCl, 154 mEq/L sodium) for hypernatremia as it will worsen the condition by providing excessive sodium load 2, 4
• Do not correct sodium too rapidly—overcorrection can be reversed by switching to D5W or D10W 1, 5
• In patients on continuous renal replacement therapy (CRRT), calculated amounts of D5W or D10W can be infused prefilter to prevent overcorrection of sodium 5
• Monitor for hyperglycemia when using D10W; if glucose exceeds 250-300 mg/dL, consider insulin infusion while continuing free water replacement 2

Special Populations

Nephrogenic Diabetes Insipidus

• D5W or D10W matches hypotonic urinary losses and is mandatory because these patients cannot concentrate urine and will worsen with isotonic fluids 2

Cirrhosis with Hypernatremia

• Free water is still needed for hypernatremia correction, though hypovolemic states may require initial volume resuscitation with albumin or lactated Ringer's before transitioning to hypotonic solutions 2

The misconception that D10 cannot be used for hypernatremia likely stems from confusion about glucose concentration rather than sodium content—both D5W and D10W are sodium-free and appropriate for hypernatremia management when used at properly adjusted rates. 1, 2