Treatment of Hypoglycemia with Available D5W and D50 Ampule
When only 5% dextrose in water (D5W) and a 20 mL ampule of 50% dextrose (D50) are available for treating severe symptomatic hypoglycemia in adults, dilute the D50 ampule with D5W to create D10 solution, then administer 5-10 gram aliquots (50-100 mL of D10) intravenously every 1-2 minutes until symptoms resolve, targeting a post-treatment glucose of 100-180 mg/dL. 1
Practical Dilution Protocol
Creating D10 from Available Supplies
Mix the 20 mL D50 ampule (containing 10 grams of dextrose) with 80 mL of D5W to create 100 mL of approximately D10 solution. This dilution strategy allows for safer, titrated dosing while avoiding the complications of undiluted D50. 1, 2
Calculate your initial dextrose requirement using: (100 – current glucose mg/dL) × 0.2 g = total grams needed. This formula helps prevent overcorrection. 1
Administration Strategy
For unconscious or unable-to-swallow patients with glucose <60 mg/dL (3.3 mmol/L), administer IV glucose immediately, even without overt clinical signs of hypoglycemia. 3, 1
Give 5-10 gram aliquots (50-100 mL of your diluted D10 solution) slowly over 1-2 minutes, then reassess. The titrated approach achieves target glucose in approximately 98% of patients within 30 minutes while minimizing dangerous overcorrection. 1, 4
Recheck blood glucose at 15 minutes post-administration; additional doses are frequently needed. 1, 5
Why Dilution is Critical
Safety Concerns with Undiluted D50
Rapid or repeated D50 boluses have been associated with cardiac arrest and hyperkalemia. 1, 2, 6
The traditional 25-gram D50 bolus causes post-treatment glucose levels of 169 mg/dL versus 112 mg/dL with titrated D10, leading to rebound hyperglycemia in 56-73% of patients. 2, 4, 7
D50 must be given slowly through a large vein to minimize thrombosis risk; concentrated solutions >10% requiring sustained infusion need central venous access. 6
Efficacy of Lower Concentration Dextrose
Studies demonstrate D10 achieves 95.9% symptom resolution compared to 88.8% with D50, with no adverse events (0/1057 patients) versus 13/310 adverse events in the D50 group. 4
Although D10 takes approximately 4 minutes longer to achieve symptom resolution (8.0 minutes vs 4.1 minutes), the safety profile is superior. 4, 8
If Dilution is Not Feasible
Using Undiluted D50 (Last Resort)
If you must use undiluted D50, administer only 10-15 grams (10-15 mL of the 20 mL ampule) initially rather than the full ampule. 2, 5
Give slowly over 1-2 minutes into a large peripheral vein, then reassess before considering additional doses. 5, 9
The FDA-approved dose for insulin-induced hypoglycemia is 10-25 grams (20-50 mL of D50), but smaller initial doses reduce overcorrection risk. 5
Why D5W Alone is Inadequate
D5W provides only 0.05 grams per mL (5 grams per 100 mL) and is designed for maintenance fluid therapy and prevention of hypoglycemia during insulin infusions, not for acute hypoglycemia treatment. 6
At standard infusion rates of 100-200 mL/hr, D5W raises serum glucose by only 9-24 mg/dL above baseline—insufficient for symptomatic hypoglycemia. 10
Monitoring Requirements
Recheck glucose at 15 minutes after initial treatment; additional doses are often required. 3, 1
Perform a second glucose check at 60 minutes, as the effect may be transient, especially in insulin overdose cases. 3, 1
During ongoing infusion (if needed), monitor glucose every 1-2 hours and assess serum potassium initially every 30-60 minutes, as dextrose can shift electrolytes. 1
Continuous Infusion if Needed
If hypoglycemia recurs or is due to long-acting insulin/sulfonylurea, start a continuous D10W infusion at 50-100 mL/hr (5-10 g/hr) after initial bolus treatment. 1
For insulin overdose cases, do not abruptly stop the dextrose infusion; reduce the rate by 50% over the final 30 minutes before cessation to avoid rebound hypoglycemia. 1
Common Pitfalls to Avoid
Never give the full 20 mL D50 ampule as a rapid bolus—this frequently causes dangerous overcorrection and rebound hyperglycemia. 2, 4, 7
Do not rely on D5W alone for acute symptomatic hypoglycemia treatment; it lacks sufficient glucose concentration for rapid correction. 6, 10
Avoid administering dextrose through small peripheral veins or giving it too rapidly, as extravasation of concentrated dextrose can cause tissue necrosis and limb loss. 9