What are the indications, dosing, and contraindications for infusing 10% dextrose in normal saline for rapid correction of hypoglycemia in adults and children?

10% Dextrose in Normal Saline Infusion

For hypoglycemia treatment, administer 10% dextrose in 5-10 gram aliquots (50-100 mL) intravenously every 1-2 minutes until symptoms resolve, targeting a post-treatment glucose of 100-180 mg/dL, which is superior to traditional bolus dosing and prevents dangerous overcorrection. 1, 2

Primary Indication: Acute Hypoglycemia Management

Initial Treatment Protocol

• Use titrated dosing with 5-10 gram aliquots of D10 administered every 1-2 minutes until mental status normalizes, which corrects blood glucose into target range in 98% of patients within 30 minutes 1, 2
• Calculate patient-specific dosing using the formula: (100 − current blood glucose in mg/dL) × 0.2 grams = total dextrose dose needed 1, 2
• This approach typically requires 10-20 grams total IV dextrose, substantially less than traditional 25-50 gram boluses 3, 4
• D10 achieves symptom resolution in 95.9% of cases with median time to recovery of 8 minutes, compared to 4 minutes with D50, but with significantly fewer adverse events (0% vs 4.2%) 5, 4

Continuous Infusion for Prolonged Hypoglycemia

For insulin overdose or ongoing hypoglycemia risk, initiate D10 continuous infusion at 100 mL/kg per 24 hours (approximately 4.2 mL/kg/hour or 7 mg/kg/minute) with appropriate maintenance electrolytes. 1, 2

• Titrate infusion rate to maintain blood glucose between 100-180 mg/dL 1, 2
• Maximum infusion rate should not exceed 5-7 mg/kg/minute to avoid hyperglycemia 2
• Older children and adults typically require substantially lower doses than the pediatric standard 2

Special Clinical Scenarios

Pediatric Maintenance Fluids

• Infants and young children requiring IV fluids should receive dextrose 10% normal saline containing solution at maintenance rates to provide 4-6 mg/kg/min glucose (6-8 mg/kg/min in newborns) to prevent hypoglycemia 3
• This is critical because infants lack adequate glycogen stores and muscle mass for gluconeogenesis 3

Neurologic Crises in Metabolic Disorders

• For tyrosinemia type I neurologic crises, administer IV 10% dextrose/normal saline at 1.5-2.0 times normal maintenance rate to inhibit δ-aminolevulinic acid production 3
• This high glucose infusion rate is essential to reverse the acute neurologic decompensation 3
• Combine with rapid-acting antihypertensives and analgesics as these crises present with pain, hypertonia, and hypertension 3

Acute Liver Failure with Hypoglycemia

• In hepatic crisis (tyrosinemia, other metabolic disorders), start IV 10% dextrose/normal saline at 1.5-2.0 times maintenance rate immediately to maintain normoglycemia 3
• Introduce small amounts of complete protein (0.25-0.5 g/kg/day) by 36-48 hours to prevent ongoing catabolism 3

Critical Monitoring Requirements

Immediate Monitoring

• Recheck blood glucose 15 minutes after initial treatment, as additional doses are frequently needed 1, 2
• Repeat glucose measurement at 60 minutes, as the dextrose effect may be temporary 1
• Monitor blood glucose every 30-60 minutes initially when starting continuous infusion, then every 1-2 hours during ongoing therapy 1, 2

Electrolyte Surveillance

• Check serum potassium and sodium levels carefully, as dextrose administration causes intracellular potassium shifts and can precipitate hypokalemia 1, 2
• Rapid dextrose administration has been associated with cardiac arrest and hyperkalemia when given repeatedly at high doses 3, 1

Contraindications and Precautions

Absolute Contraindications

• Do not use hypotonic dextrose solutions (D5 0.2% NaCl, D5 0.45% NaCl) for maintenance fluids in acutely ill children, as they increase risk of hospital-acquired hyponatremia and hyponatremic encephalopathy 3
• Acutely ill patients have nonosmotic arginine vasopressin release (pain, nausea, stress, postoperative state) causing water retention and syndrome of inappropriate antidiuresis 3

Critical Pitfalls to Avoid

• Never reflexively administer full 25-50 gram doses of dextrose, as this causes excessive blood glucose elevation (mean post-treatment glucose 169 mg/dL with D50 vs 112 mg/dL with D10) 3, 5, 4
• Never abruptly discontinue dextrose infusion in insulin overdose patients 1, 2
• Reduce infusion rate by 50% over the final 30 minutes before discontinuing to prevent rebound hypoglycemia 1, 2
• Avoid D50 when possible, as it is highly irritating to veins; dilution to D10 or D25 is preferable 2

Comparative Efficacy Data

D10 vs D50 Performance

• D10 administered in 5-gram aliquots results in median total dose of 10 grams vs 25 grams with D50 (p < 0.001) 4
• Post-treatment blood glucose is significantly lower with D10 (6.2 mmol/L) compared to D50 (9.4 mmol/L, p = 0.003) 4
• Both achieve nearly complete resolution of hypoglycemia: 99.2% (D10) vs 98.7% (D50) 5
• D10 requires additional doses in 19.5% of cases vs 8.1% with D50, but this is offset by superior glycemic control and safety profile 5

Dosing Summary by Clinical Context

Acute Symptomatic Hypoglycemia

• Adults: 5-10 gram aliquots (50-100 mL D10) IV every 1-2 minutes 1, 2
• Children: 15-20 grams total for moderate hypoglycemia; 0.5-1.0 g/kg requires 5-10 mL/kg of D10 1, 2

Continuous Infusion

• Pediatric: 100 mL/kg per 24 hours (7 mg/kg/min) 1, 2
• Adult: Substantially lower rates, titrated to maintain glucose 100-180 mg/dL 2

Metabolic Crisis

• All ages: 1.5-2.0 times maintenance rate 3