preterm infants; monitor liver function tests, if abnormalities occur consider discontinuation or dosage reduction. ( 5.7 , 8.4 ) • electrolyte imbalance and fluid overload : monitor daily fluid balance, blood electrolyte levels, correct as needed. ( 5.8 , 8.4 ) 5.1 hyperglycemia and hyperosmolar hyperglycemic state the use of dextrose infusions in patients with diabetes mellitus or impaired glucose tolerance may worsen hyperglycemia. administration of dextrose at a rate exceeding the patient's utilization rate may lead to hyperglycemia, coma, and death. patients with underlying confusion and renal impairment who receive dextrose infusions, may be at greater risk of developing hyperosmolar hyperglycemic state. monitor blood glucose levels and treat hyperglycemia to maintain optimum levels while administering dextrose injection. insulin may be administered or adjusted to maintain optimal blood glucose levels during dextrose injection administration. 5.2 hypersensitivity reactions hypersensitivity reactions including anaphylaxis have been reported with dextrose infusions. stop infusion immediately and treat patient accordingly if signs or symptoms of a hypersensitivity reaction develop. signs or symptoms may include: tachypnea, dyspnea, hypoxia, bronchospasm, tachycardia, hypotension, cyanosis, vomiting, nausea, headache, sweating, dizziness, altered mentation, flushing, rash, urticaria, erythema, pyrexia, and chills. 5.3 risk of infections patients who require parenteral nutrition are at high risk of infections because the nutritional components of these solutions can support microbial growth. the risk of infection is increased in patients with malnutrition-associated immunosuppression, hyperglycemia exacerbated by dextrose infusion, long-term use and poor maintenance of intravenous catheters, or immunosuppressive effects of other concomitant conditions, drugs, or other components of the parenteral formulation (e.g., lipid emulsion). to decrease the risk of infectious complications, ensure aseptic technique in catheter placement and maintenance, as well as aseptic technique in the preparation and administration of the nutritional formula. monitor for signs and symptoms (including fever and chills) of early infections, including laboratory test results (including leukocytosis and hyperglycemia) and frequent checks of the parenteral access device and insertion site for edema, redness and discharge. 5.4 refeeding syndrome refeeding severely undernourished patients may result in refeeding syndrome, characterized by the intracellular shift of potassium, phosphorus, and magnesium as the patient becomes anabolic. thiamine deficiency and fluid retention may also develop. to prevent these complications, monitor severely undernourished patients and slowly increase nutrient intakes. 5.5 vein damage and thrombosis dextrose injection is for admixture with amino acids or dilution with other compatible intravenous fluids. it is not for direct intravenous infusion. administer solutions containing more than 5% dextrose or with an osmolarity of ≥ 900 mosm/l through a central vein [see dosage and administration ( 2.1 )] . the infusion of hypertonic solutions into a peripheral vein may result in vein irritation, vein damage, and/or thrombosis. the primary complication of peripheral access is venous thrombophlebitis, which manifests as pain, erythema, tenderness or a palpable cord. remove the catheter as soon as possible, if thrombophlebitis develops. 5.6 aluminum toxicity dextrose injection contains no more than 25 mcg/l of aluminum. however, with prolonged parenteral administration in patients with renal impairment, the aluminum contained in dextrose injection may reach toxic levels. preterm infants are at greater risk because their kidneys are immature, and they require large amounts of concomitant calcium and phosphate solutions that contain aluminum. patients with renal impairment, including preterm infants, who receive parenteral levels of aluminum at greater than 4 to 5 mcg/kg/day, accumulate aluminum at levels associated with central nervous system and bone toxicity. tissue loading may occur at even lower rates of administration of total parenteral nutrition products. 5.7 risk of parenteral nutrition associated liver disease parenteral nutrition associated liver disease (pnald) has been reported in patients who receive parenteral nutrition for extended periods of time, especially preterm infants, and can present as cholestasis or steatohepatitis. the exact etiology is not entirely clear and is likely multifactorial. if dextrose injection-treated patients develop abnormal liver function tests consider discontinuation or dosage reduction. 5.8 electrolyte imbalance and fluid overload electrolyte deficits, particularly in serum potassium and phosphate, may occur during prolonged use of concentrated dextrose solutions. depending on the volume and rate of infusion, the intravenous administration of concentrated dextrose solutions can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, overhydration, congested states or pulmonary edema. the risk of dilutional states is inversely proportional to the electrolyte concentrations in the administered solution. the risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations in the solution. monitor blood electrolyte levels, correct fluid and electrolyte imbalances, and administer essential vitamins and minerals as needed. monitor daily fluid balance.

other compatible intravenous fluids or used as an admixture with amino acids. it is not for direct intravenous infusion . preparation prior to administration • because additives may be incompatible, evaluate all additions to the plastic container for compatibility and stability of the resulting preparation. consult with a pharmacist, if available. if it is deemed advisable to introduce additives, use aseptic technique and mix thoroughly. • inspect dextrose injection to ensure precipitates have not formed during the mixing or addition of additives. discard the bag if precipitates are observed. some opacity of the plastic container (due to moisture absorption during sterilization process) may be observed. this is normal and does not affect the solution quality or safety. the opacity will diminish gradually. • use promptly after admixing or dilution. • for single use only; discard unused portion important administration instructions • set the vent to the closed position on a vented intravenous administration set to prevent air embolism. • use a dedicated line without any connections to avoid air embolism. • prior to infusion, visually inspect the diluted dextrose solution for particulate matter. the solution should be clear and there should be no precipitates. do not administer unless solution is clear and container is undamaged. • the choice of a central or peripheral venous route of infusion should depend on the osmolarity of the final infusate. solutions with greater than 5% dextrose or with osmolarity of greater than or equal to 900 mosm/l must be infused through a central catheter [see warnings and precautions ( 5.5 )] . 2.2 dosing information caution: dextrose injection is not for direct intravenous infusion. prior to administration, dextrose injection must be diluted with other compatible intravenous fluids or used as an admixture with amino acids. individualize the dosage of dextrose injection based on the patient's clinical condition (ability to adequately metabolize dextrose), body weight, nutritional and fluid requirements, as well as additional energy given orally or enterally to the patient. the administration rate should be governed, especially during the first few day of therapy, by the patient's tolerance to dextrose. daily intake of amino acids and dextrose should be increased gradually to the maximum required dose as indicated by frequent determinations of blood glucose levels. 2.3 discontinuation of dextrose injection to reduce the risk of hypoglycemia, a gradual decrease in flow rate in the last hour of infusion should be considered.

ommon adverse reactions are hyperosmolar syndrome, infection both systemic and at the injection site, vein thrombosis or phlebitis, and hypervolemia. ( 6 ) to report suspected adverse reactions, contact icu medical, inc. at 1-800-441-4100, or fda at 1-800-fda-1088 or www.fda.gov/medwatch .

a breastfed infant, or the effects on milk production. the developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for dextrose injection and any potential adverse effects on the breastfed infant from dextrose injection or from the underlying maternal condition. 8.4 pediatric use neonates, especially those born premature and with low birth weight are at increased risk of developing hypo – or hyperglycemia and therefore need close monitoring during treatment with intravenous glucose infusions to ensure adequate glycemic control in order to avoid potential long term adverse effects. hypoglycemia in the newborn can cause prolonged seizures, coma and brain damage. hyperglycemia has been associated with intraventricular hemorrhage, late onset bacterial and fungal infection, retinopathy of prematurity, necrotizing enterocolitis, bronchopulmonary dysplasia, prolonged length of hospital stay, and death. plasma electrolyte concentrations should be closely monitored in the pediatric population as this population may have impaired ability to regulate fluids and electrolytes. in very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage. because of immature renal function, preterm infants receiving prolonged treatment with dextrose injection, may be at risk aluminum toxicity [see warnings and precautions ( 5.6 )] . patients, including pediatric patients, may be at risk for parenteral nutrition associated liver disease (pnald) [see warnings and precautions ( 5.7 )] . 8.5 geriatric use clinical studies of dextrose injection did not include sufficient numbers of patients aged 65 and over to determine whether they respond differently from other younger patients. other reported clinical experience has not identified differences in responses between the elderly and younger patients.

of immature renal function, preterm infants receiving prolonged treatment with dextrose injection, may be at risk aluminum toxicity [see warnings and precautions ( 5.6 )] . patients, including pediatric patients, may be at risk for parenteral nutrition associated liver disease (pnald) [see warnings and precautions ( 5.7 )] .

tore between 20°c to 25°c (68°f to 77°f). [see usp controlled room temperature.] do not freeze.