From the Guidelines
For NPO diabetic patients, the recommended intravenous fluid is typically 5% dextrose in 0.45% normal saline (D5 1/2NS) infused at a rate of 100-125 mL/hour, as this provides both glucose to prevent hypoglycemia and electrolytes to maintain fluid balance, with blood glucose monitoring every 4-6 hours and a target range of 140-180 mg/dL for most hospitalized patients 1.
Key Considerations
- The choice of intravenous fluid should prioritize the prevention of hypoglycemia and the maintenance of fluid balance, with consideration of the patient's overall clinical status and the potential for electrolyte imbalances.
- The use of isotonic intravenous fluids such as lactated Ringer’s and normal saline solution may be necessary in cases of severe dehydration, shock, or altered mental status, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines 1.
- For patients with diabetes mellitus, the management of hyperglycemia is crucial, with a preferred target range of 140-180 mg/dL for most hospitalized patients, and the use of insulin therapy, including basal and sliding scale regimens, as necessary to achieve this target range 1.
- Potassium levels should be monitored closely, as insulin therapy can cause hypokalemia, and potassium replacement may be necessary to maintain levels above 4.0 mEq/L.
Management Approach
- Patients should have their blood glucose monitored regularly, with adjustments to their insulin regimen as needed to maintain the target glucose range.
- The use of a basal-plus-correction insulin regimen is recommended for patients with poor oral intake or those who are receiving nothing by mouth, as this approach allows for more precise control of glucose levels and reduces the risk of hypoglycemia 1.
- In cases where intravenous insulin therapy is necessary, a validated written or computerized protocol should be used to guide adjustments in the infusion rate, with consideration of glycemic fluctuations and insulin dose 1.
From the Research
Fluid Recommendations for NPO Status and Diabetes Mellitus
- For patients with Nothing Per Oral (NPO) status and diabetes mellitus, the choice of intravenous fluid is crucial to manage blood glucose levels and hydration.
- A study published in 2014 2 compared oral versus intravenous fluids for lowering blood glucose in emergency department patients with hyperglycemia, and found that both routes were equally efficacious in lowering blood glucose levels.
- However, another study from 2006 3 suggested that using dextrose-containing solutions for intravenous fluid replacement may cause significant hyperglycemia, even in non-diabetic patients.
- For patients with diabetes, a 2.5% glucose solution with electrolytes may be used for intravenous hydration, and the infusion rate can be guided by kinetic analysis to reach a predetermined glucose level and volume expansion 4.
- Balanced crystalloids, such as Ringer lactate solution or Plasma-Lyte A solution, may be preferred over saline for acute management of adults with diabetic ketoacidosis, as they do not cause acidosis and may lead to faster resolution of DKA 5.
- Oral electrolyte solutions, such as glucose-containing reduced osmolarity World Health Organization ORS, may be used for rehydration in patients with mild dehydration, but are not recommended for patients with severe dehydration or those who require intravenous fluids 6.
Key Considerations
- The choice of fluid should be individualized based on the patient's specific needs and medical condition.
- Blood glucose levels should be closely monitored when using intravenous fluids, especially in patients with diabetes.
- The use of dextrose-containing solutions should be avoided in patients with hyperglycemia, and balanced crystalloids may be a better option for patients with diabetic ketoacidosis.