How to make gir infusion for hypoglycemia

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GIR glucose infusion rate calculation formula hypoglycemia neonatal preparation

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GIR (Glucose Infusion Rate) Infusion for Hypoglycemia

1. Definition & Target Values

Patient	Hypoglycemia threshold	Target GIR
Term neonate	Serum glucose < 40 mg/dL	3-5 mg/kg/min
Preterm neonate	Serum glucose < 40 mg/dL	5-8 mg/kg/min (up to 14 mg/kg/min max)
Infant of diabetic mother	< 40 mg/dL	Start 8-10 mg/kg/min

The Harriet Lane Handbook, 23rd ed., Table 18.5
Mulholland & Greenfield's Surgery, 7e, p. 5298

2. The GIR Formula

There are two equivalent forms:

Form 1 (Harriet Lane):

GIR (mg/kg/min) = 0.167 × [Dextrose % concentration] × [Infusion rate (mL/hr)] ÷ Weight (kg)

Form 2 (expanded units):

GIR (mg/kg/min) = [Rate (mL/hr) × Dextrose concentration (g/L)] ÷ [Weight (kg) × 60 min/hr]

Note: Dextrose % × 10 = g/L. For example, D10W = 100 g/L; D5W = 50 g/L.

3. How to Prepare the GIR Infusion

Step 1 - Choose your dextrose concentration

Concentration	Access required	Use when
D5W (5%)	Peripheral IV	Mild hypoglycemia, oral supplementation adjunct
D10W (10%)	Peripheral IV	Standard first-line IV treatment
D12.5%	Peripheral IV (max)	Escalation when D10W insufficient
D15W-D20W+	Central line only	Persistent/refractory hypoglycemia
D25W or D50W	Avoid in neonates	Causes rebound hypoglycemia and dangerous hyperosmolarity

Step 2 - Acute bolus (if symptomatic or glucose < 40 mg/dL)

Give D10W at 2 mL/kg IV (= 200 mg/kg glucose dose) as a slow push over 1-2 minutes
Recheck glucose in 20-30 minutes

Step 3 - Set up the continuous infusion

To find the infusion rate needed:

Rearrange the formula:

Rate (mL/hr) = [Target GIR × Weight (kg) × 60] ÷ Dextrose concentration (g/L)

Worked example:

Baby weighs 2.5 kg
Target GIR = 6 mg/kg/min
Using D10W (= 100 g/L)

Rate = (6 × 2.5 × 60) ÷ 100 = 900 ÷ 100 = 9 mL/hr

Step 4 - Prepare the solution

For a D10W infusion:

Take 500 mL bag of D5W + add 50 mL of D50W to make ~D10W (practical ward method), OR
Use a pre-made D10W bag

For higher concentrations (e.g., D12.5%):

Mix D10W and D50W in calculated proportions, or use pharmacy-prepared bags
Per RCH neonatal guidelines, an additive calculation table is used for 500 mL preparations

4. Escalation Protocol

Check glucose every 30-60 minutes after any change
If hypoglycemia persists, increase GIR by 2 mg/kg/min increments (no more than 2 mg/kg/min per 2-hour interval)
Maximum peripheral IV concentration: D12.5% - insert a central line if concentrations higher than this are needed
Escalate to D15W, D20W only via central access (umbilical catheter or PICC)
Maximum GIR typically used: 12-15 mg/kg/min; if still refractory, consider glucagon infusion or endocrine consult

5. Weaning the Infusion

Once blood glucose has been stable for 12-24 hours:

Decrease IV infusion by 1-2 mL/hr every 3-4 hours
Maintain glucose > 60 mg/dL throughout
Never abruptly stop the infusion - rebound hypoglycemia can occur, especially in hyperinsulinemic states

6. Key Safety Points

Do NOT use D25W or D50W as IV boluses in neonates - they cause dangerous hyperosmolarity and rebound hypoglycemia
Concentrations > 12.5% must go through a central line to prevent extravasation/thrombophlebitis
If an infant requires > 10-12 mg/kg/min to maintain normoglycemia, consider hyperinsulinism (e.g., Beckwith-Wiedemann, infant of diabetic mother, sulphonylurea exposure) and obtain insulin/C-peptide levels
Always confirm a bedside glucometer reading with a laboratory serum glucose before escalating treatment

Clinical source: The Harriet Lane Handbook, 23rd ed. (Johns Hopkins Hospital), Chapter 18, Table 18.5 and GIR formula; Mulholland & Greenfield's Surgery, 7e, p. 5298. Aligns with UCSF Neonatal Hypoglycemia Protocol and RCH Neonatal Hypoglycaemia Guidelines.

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