What are the next steps for a patient who is nil by mouth (nothing by mouth) with normal glucose levels but elevated ketones and has a nasogastric (NG) tube in place?

From the Guidelines

For a patient who is nil by mouth with normal glucose but elevated ketones and has an NG tube in place, the next step is to start home enteral nutrition (HEN) immediately according to the previously established nutritional care plan once appropriate tube placement has been confirmed. This approach is supported by the ESPEN practical guideline on home enteral nutrition, which states that a patient with a nasogastric tube can start HEN immediately once tube placement is confirmed 1. Key considerations include:

• Confirming appropriate NG tube placement before commencing HEN
• Following the previously established nutritional care plan
• Exercising caution if refeeding syndrome is suspected and following appropriate guidelines to prevent metabolic complications, as noted in the commentary accompanying the ESPEN guideline 1
• Monitoring the patient's condition, including glucose and ketone levels, to adjust the nutritional support as needed The presence of elevated ketones despite normal glucose levels indicates that the body is utilizing fat for energy due to the lack of carbohydrate intake, and initiating HEN will help provide the necessary carbohydrates to reduce ketone production. It is crucial to prioritize the patient's nutritional needs and address the ketosis while maintaining hydration, as guided by the most recent and highest quality evidence available 1.

From the Research

Patient Assessment

• The patient is nil by mouth with normal glucose levels but elevated ketones (0.9) and has a nasogastric (NG) tube in place.
• The presence of elevated ketones indicates that the patient is likely in a state of ketosis, which can be a concern in patients who are nil by mouth.

Management Considerations

• According to a study on the effect of glucose and insulin infusion on the fall of ketone bodies during treatment of diabetic ketoacidosis 2, the use of hypertonic glucose has been recommended to hasten the clearance of blood ketone bodies.
• Another study on intravenous dextrose for children with gastroenteritis and dehydration found that administration of a dextrose-containing bolus compared with normal saline resulted in a greater reduction in serum ketone levels 3.
• A study on clinical impact of rapid intravenous rehydration with dextrose serum in children with acute gastroenteritis also found that changes in glucose and ketone levels were more favorable in the group receiving dextrose serum 4.

NG Tube Management

• A study on clinical experience with modified enteral formulas for patients with diabetes found that specialized formulas with increased fiber may improve glycemic control, although the concomitant increases in viscosity of these formulas may limit their usefulness for tube feeding 5.
• The use of a 2.5% glucose solution for intravenous hydration in patients with Type II diabetes has also been studied, and a nomogram was created to serve as a guide to fluid therapy in these patients 6.

Next Steps

• Consider administering a dextrose-containing solution to help reduce serum ketone levels.
• Monitor the patient's glucose and ketone levels closely to adjust the treatment plan as needed.
• Evaluate the patient's overall health and nutritional status to determine the best course of management for their condition.