During my very brief stint as your TR I have received two separate requests to discuss dextrose-containing fluids so for today’s POTD we’re going to review the use of these dextrose fluids based on their various formulations.
Dextrose containing fluids are often used in the management of hypoglycemia. Hypoglycemia is defined as an abnormally low plasma glucose level, typically below 60 or 70 mg/dl in adults. Oral repletion is preferred in patients who are awake, alert, and able to swallow. However, for patients with severe hypoglycemia or altered mental status, you likely need to give intravenous dextrose containing fluids. These fluids are commonly referred to by the percent of glucose present in the solution, such as D50, D10, D5, etc.
D50 contains 25g of glucose in 50mL of water. This usually comes as a prefilled syringe and is commonly referred to as “an amp of D50.” Admittedly this is the dextrose containing fluid I find myself ordering the most for acute hypoglycemia. It is readily available (can be found in any of the ED omnicells) and provides a quick bolus of glucose with about five times the amount of glucose present in a normal adult’s blood. However, D50’s hypertonic nature increases the risk of vascular and tissue damage. If administered into a small vein D50 can be irritating and may cause thrombophlebitis. Additionally, it is also prone to extravasation from the vein leading to skin irritation and, in severe cases, local scarring or skin necrosis. Given these complications, some people advocate for the use of D10 instead.
D10 often comes as 10g of glucose in 100mL of fluid. This fluid has a lower osmolarity compared to D50, which reduces the risk of extravasation and thrombophlebitis. The lower concentration of D10 also allows for easier titration to ensure the patient becomes normoglycemic without overshooting and causing hyperglycemia. From my googles and discussions, the primary defense against using D10 in acute hypoglycemia seems to be a concern about the time required to give D10 as compared to D50. However, it’s important to note that one amp of D50 should be infused over 2-3 minutes to avoid extravasation. Studies show that a 200mL bolus of D10 (containing 20g of glucose) can be administered via pressure bag and will enter the patient’s bloodstream as quickly as slow pushing an amp of D50 (containing 25g of glucose). At Maimo, D10 can be found in the ED pharmacy, but after pharmacy leaves at night you would have to get it sent down from central pharmacy (unless you’re in peds, where there is usually a few bag of D10).
Speaking of pediatrics… the treatment of hypoglycemia is slightly different in children. To minimize vascular complications associated with highly concentrated dextrose fluids, we opt for using weight based volumes of more dilute fluids, such as D10 or D25.
The general rule of thumb is neonates and infants (less than 1 year old) should get D10, while toddlers and children (1-8 years old) should get D25. Adolescents (greater than 8 years old) can be given D50. Regardless of the dextrose concentration, the volume administered should provide 0.5g dextrose per kg. To conveniently calculate the dose in milliliters, we use the “Rule of 50” – multiply the type of dextrose solution by a factor of 5, 2, or 1 (ml/kg) to give a total of 50.
D10: 10 x 5 = 50, so give 5ml/kg
D25: 25 x 2 = 50, so give 2ml/kg
D50: 50 x 1 = 50, so give 1ml/kg
Overall these rules can be summarized as:
Neonates and infants <1 YO, give D10 at 5 ml/kg
Toddlers and children 1-8 YO, give D25 at 2ml/kg
Adolecents > 8YO, give D50 at 1ml/kg
Of note, we do not have D25 fluids in the Maimo ER so usually I’ve seen people give D10 regardless of the patient’s age. Though you can always get D25 from PICU or central pharmacy in a pinch you can always make it out of an amp of D50. To make D25, discard 25mL from the D50 ampule and then add 25mL of NS or sterile water back into the ampule. Similarly, to make D10, discard 40mL from the D50 ampule and replace it with 40mL of NS or sterile water.
And last but not least, D5 is another fluid option with 5g of dextrose in 100ml of fluid. This is another commonly used dextrose-containing fluid that can be found in all the ED Omni cells. However, this fluid is too dilute to be recommended as a bolus treatment for acute hypoglycemia. Instead, where it shines is as a maintenance fluid to maintain normoglycemia and prevent rebound hypoglycemic events.
Sources:
https://www.emdocs.net/em3am-hypoglycemia/
https://www.aliem.com/d50-vs-d10-severe-hypoglycemia-emergency-department/
https://pemcincinnati.com/blog/521-50-dextrose-volume-hypoglycemia/