From the Guidelines
To manage starvation-related ketosis in NPO patients, administer intravenous dextrose solutions, typically D5W or D10W at 75-125 mL/hour, adjusted based on blood glucose monitoring, as this approach is crucial for preventing complications like muscle wasting and immune dysfunction. When managing starvation-related ketosis, it is essential to consider the patient's overall nutritional status and the underlying cause of the ketosis. According to 1, ingestion of 150–200 g carbohydrate daily can help prevent starvation ketosis, but this may not be feasible in NPO patients. In such cases, intravenous dextrose solutions can provide the necessary carbohydrates to help alleviate ketosis. For patients requiring prolonged NPO status (>24-48 hours), transitioning to total parenteral nutrition (TPN) providing 25-35 kcal/kg/day with appropriate glucose, protein, and lipid components can help meet their nutritional needs. Key considerations in managing starvation-related ketosis include:
- Monitoring serum glucose every 4-6 hours initially, then adjusting to every 6-8 hours once stable, aiming for blood glucose levels between 100-180 mg/dL
- Electrolyte replacement, particularly potassium, magnesium, and phosphate, which can be depleted during refeeding
- Regular assessment of acid-base status through arterial blood gases or venous bicarbonate levels to track ketosis resolution
- Considering insulin administration alongside glucose for patients with diabetes to prevent hyperglycemia while addressing ketosis, as suggested by 1. However, the most recent and highest quality study 1 provides the most relevant guidance for managing starvation-related ketosis in NPO patients.
From the FDA Drug Label
Glucagon for Injection is effective in treating hypoglycemia only if sufficient hepatic glycogen is present. Patients in states of starvation, with adrenal insufficiency or chronic hypoglycemia may not have adequate levels of hepatic glycogen for Glucagon for Injection administration to be effective. Patients with these conditions should be treated with glucose.
The management of starvation-related ketosis in a patient who is nothing by mouth (NPO) should be treated with glucose, as glucagon may not be effective due to decreased hepatic glycogen levels 2, 2.
From the Research
Management of Starvation-Related Ketosis
The management of starvation-related ketosis in a patient who is nothing by mouth (NPO) involves several key considerations:
- Monitoring of electrolyte levels, particularly phosphorus, potassium, and magnesium, as patients with pH < 7.3 may benefit from baseline serum levels 3
- Generous vitamin and electrolyte supplementation while monitoring closely and increasing the calorie intake reasonably rapidly from 10 to 20 kcal/kg/24 hours 4
- Awareness of the risk of refeeding syndrome, which can be managed with low-calorie feeds, but sometimes requires a halt in feeds until electrolyte imbalances are managed 3, 4
- Intravenous fluids, thiamine, dietetic input, and electrolyte replacement are vital in the management of starvation ketoacidosis 5
- Gradual resumption of oral feeding to avoid potentially fatal inappropriate renutrition syndrome 6
Refeeding Syndrome
Refeeding syndrome is a significant concern in the management of starvation-related ketosis:
- It can occur in patients who have had no or very little nutrition for over 5 days 4
- Hypophosphataemia, hypomagnesaemia, and hypokalaemia are the main clinical problems, with a risk of sudden death 4
- Thiamine deficiency can also occur, with a risk of Wernike's encephalopathy/Korsakoff psychosis 4
- If problems do occur, the feed should be slowed, reduced, or rarely stopped while fluid and electrolyte issues are corrected 4