Maintenance IV Fluid After Acute Hypoglycemia Correction
After correcting acute hypoglycemia with IV dextrose bolus, transition immediately to a continuous dextrose-containing maintenance fluid—specifically 5% dextrose in 0.45% or 0.9% saline—to prevent recurrent hypoglycemia while the underlying cause is addressed. 1
Immediate Post-Correction Fluid Strategy
Switch to 5% dextrose with 0.45–0.75% NaCl as the maintenance IV fluid once the initial hypoglycemic episode is corrected and blood glucose exceeds 70 mg/dL 1, 2
This dextrose-containing maintenance fluid should be started immediately after the rescue dextrose bolus to provide continuous carbohydrate substrate and prevent recurrent hypoglycemia 1
The maintenance infusion rate should deliver approximately 150–200 g of carbohydrate per 24 hours to suppress ongoing counter-regulatory responses and prevent starvation ketosis 3
Specific Clinical Context: Insulin Infusion
If the patient remains on an insulin infusion (e.g., for DKA or critical illness), never discontinue the insulin—instead add dextrose to the IV fluid while maintaining the same insulin rate 1, 3
When plasma glucose falls to 250 mg/dL during DKA treatment, the standard protocol mandates switching to D5W with 0.45–0.75% saline while continuing insulin at the same rate to allow ketone clearance 1, 3
For euglycemic DKA (initial glucose <250 mg/dL), start dextrose-containing fluids simultaneously with insulin initiation to prevent hypoglycemia while clearing ketones 3
Monitoring Requirements
Check blood glucose every 1–2 hours after restarting or continuing any insulin therapy to detect early recurrence of hypoglycemia 2
Monitor serum potassium every 2–4 hours because insulin drives potassium intracellularly, and severe hypokalemia (<2.5 mEq/L) increases mortality 3
Maintain serum potassium 4.0–5.0 mEq/L by adding 20–30 mEq/L potassium to maintenance fluids once adequate urine output is confirmed 1, 3
Electrolyte Composition of Maintenance Fluid
Add 20–30 mEq/L potassium to each liter of maintenance fluid using a mixture of 2/3 potassium chloride (or acetate) and 1/3 potassium phosphate 1, 3
This potassium supplementation is mandatory in patients receiving insulin infusions because total-body potassium depletion averages 1.0 mmol/kg even when serum levels appear normal 3
Alternative Dextrose Concentrations
10% dextrose (D10) infusion is an acceptable alternative that provides more sustained glucose delivery with lower risk of rebound hyperglycemia compared to repeated D50 boluses 4, 5
D10 infusions result in fewer adverse events (0% vs. 4.2% with D50) and lower post-treatment glucose levels (6.2 mmol/L vs. 8.5 mmol/L) while achieving 99.2% resolution of hypoglycemia 5
The trade-off is that D10 requires approximately 4 minutes longer to achieve symptom resolution (8.0 minutes vs. 4.1 minutes with D50) and a higher rate of repeat dosing (19.5% vs. 8.1%) 5
Critical Pitfalls to Avoid
Never hold or discontinue insulin when glucose normalizes during DKA treatment; continuous insulin is required for ketone clearance regardless of glucose level 3
Never stop IV insulin abruptly without a 2–4 hour overlap with subcutaneous basal insulin, as this is the most common cause of recurrent DKA 1, 3, 2
Do not restart insulin if serum potassium is <3.3 mEq/L; this is an absolute contraindication that can precipitate fatal cardiac arrhythmias (Class A evidence) 1, 3
Avoid prolonged insulin interruption after hypoglycemia correction, as delays beyond achieving glucose >70 mg/dL cause rebound hyperglycemia and metabolic decompensation 2
Pediatric and Special Populations
In children receiving IV maintenance fluids, glucose provision should be guided by at least daily blood glucose monitoring to prevent hypoglycemia 1
For critically ill children, balanced isotonic solutions with appropriate glucose content should be used, with glucose monitoring to prevent both hypoglycemia and hyperglycemia 1
Total daily fluid intake should include all IV fluids, medications, line flushes, and enteral intake to prevent fluid overload while ensuring adequate glucose delivery 1