How is insulin administered in a nil per oral (nothing by mouth) patient?

Insulin Administration in Nil Per Oral (NPO) Patients

For patients who are nil per oral (NPO), a basal-plus-correction insulin regimen is the preferred treatment approach, consisting of basal insulin (0.1-0.25 U/kg/day) plus corrective doses of rapid-acting insulin based on glucose levels. 1, 2

Insulin Regimen Components for NPO Patients

Basal Insulin

• Use long-acting insulin (glargine or detemir) at 0.1-0.25 U/kg/day 2
• Lower doses (0.1-0.15 U/kg/day) should be used for:
  • Elderly patients (>65 years)
  • Patients with renal insufficiency
  • Patients at higher risk of hypoglycemia 1, 2
• For patients previously on insulin at doses ≥0.6 U/kg/day, reduce the total daily dose by 20% 2

Correction Insulin

• Use rapid-acting insulin (lispro, aspart, or glulisine) for correction doses
• Administer every 4-6 hours based on blood glucose monitoring 1
• Dosing should follow a standardized protocol with predefined adjustments based on glucose readings 1

Monitoring and Administration

• Perform point-of-care glucose testing every 4-6 hours 1, 2
• Adjust basal insulin dose every 1-2 days based on glucose patterns 2
• Target glucose levels of 7.8-10 mmol/L (140-180 mg/dL) for most patients 1
• Lower targets of 6.1-7.8 mmol/L (110-140 mg/dL) may be appropriate for specific patients (e.g., cardiac surgery, acute ischemic cardiac or neurologic events) if achievable without significant hypoglycemia 1

Critical Care Setting

• In critical care units, continuous intravenous insulin infusion is the preferred method 1
• IV insulin should be administered according to validated written or computerized protocols 1
• When transitioning from IV to subcutaneous insulin:
  • Give subcutaneous basal insulin 1-2 hours before discontinuing IV insulin 1
  • Convert to basal insulin at 60-80% of the daily IV infusion dose 1

Important Cautions

Avoid Sliding Scale Insulin Alone

• The sole use of sliding-scale insulin (without basal insulin) is strongly discouraged 1, 2
• This approach leads to poor glycemic control and glucose fluctuations 2

Hypoglycemia Prevention

• Implement a standardized hospital-wide hypoglycemia treatment protocol 1
• Be vigilant for hypoglycemia triggers in NPO patients:
  • Sudden reduction of corticosteroid dose
  • Reduced infusion rate of intravenous dextrose
  • Unexpected interruption of parenteral feedings 1
• Document all hypoglycemic episodes and track for quality improvement 1

Special Considerations

• For patients receiving parenteral nutrition, insulin dosing should be adjusted based on the carbohydrate content of the nutrition 1
• When transitioning back to oral intake, adjust insulin regimen accordingly, with prandial insulin added to the regimen 1
• For patients with severe hyperglycemia (>300 mg/dL), consider higher initial basal insulin doses (0.2-0.3 U/kg/day) 2

By following this structured approach to insulin administration in NPO patients, healthcare providers can effectively manage blood glucose levels while minimizing the risk of hypoglycemia and its associated complications.