What intravenous (IV) fluid and rate should be administered to a diabetic patient who is nil per os (NPO)?

From the Guidelines

For a diabetic patient who is nil per os (NPO), the recommended IV fluid is 0.9% NaCl or other crystalloid at a clinically appropriate rate aiming to replace 50% of the estimated fluid deficit in the first 8–12 hours, as stated in the 2025 standards of care in diabetes 1.

Key Considerations

• The choice of IV fluid and rate should be based on the patient's hydration status, with severe hypovolemia requiring more aggressive fluid replacement.
• Insulin therapy should be initiated alongside IV fluid administration, with a fixed-rate IV insulin infusion or nurse-driven protocol with a variable rate based on glucose values.
• Potassium supplementation should be added to the IV fluid as needed to keep serum potassium between 4 and 5 mmol/L.
• Blood glucose targets should be maintained between 150 and 200 mg/dL until resolution of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).

IV Fluid Administration

• The IV fluid rate should be adjusted based on the patient's cardiovascular status, renal function, and other medical conditions.
• Hemodynamic monitoring and pressors may be necessary in patients with cardiac compromise.

Insulin Therapy

• Regular insulin should be administered as an IV infusion, with dosing based on frequent blood glucose monitoring (every 2-4 hours).
• The insulin regimen should be adjusted to maintain blood glucose targets and prevent hypoglycemia and ketosis.

Monitoring and Adjustments

• Electrolytes, renal function, venous pH, osmolality, and glucose should be monitored every 2-4 hours until stable.
• The IV fluid rate and insulin regimen should be adjusted as needed to maintain the patient's metabolic stability during the NPO period.

From the FDA Drug Label

For intravenous use, Humulin R U-100 should be used at concentrations from 0.1 unit/mL to 1 unit/mL in infusion systems with the infusion fluids 0.9% sodium chloride using polyvinyl chloride infusion bags. The IV fluid that should be administered to a diabetic patient who is NPO is 0.9% sodium chloride. The rate of administration is not explicitly stated in the provided drug labels for a diabetic patient who is NPO, but for dextrose administration, the maximum rate at which dextrose can be infused without producing glycosuria is 0.5 g/kg of body weight/hour. However, this information is for dextrose and not directly applicable to the administration of insulin in 0.9% sodium chloride. Therefore, the rate of administration of 0.9% sodium chloride with insulin for a diabetic patient who is NPO cannot be determined from the provided information 2.

From the Research

IV Fluid Administration for Diabetic Patients who are NPO

• The ideal IV fluid and rate for a diabetic patient who is NPO is not explicitly stated in the provided studies, but some insights can be gathered from the available evidence.
• A study from 3 emphasizes the importance of proper management of diabetic patients who are NPO, highlighting the dangers of "hold-the-insulin" routines and the need for guidelines to ensure excellent nursing care.
• Regarding IV fluid administration, a study from 4 investigated the effect of 5% dextrose infusions on blood glucose levels in non-diabetic patients, finding that it did not cause significant hyperglycemia.
• Another study from 5 compared the effectiveness of different interventions for emergency care of hypoglycemia and diabetic ketoacidosis, including the use of 10% dextrose (D10) and 50% dextrose (D50), and found that both are effective options.
• A study from 6 evaluated intraoperative glucose control in diabetic and non-diabetic patients during cardiac surgery, using a modified insulin regimen with a fixed rate infusion of regular insulin and a variable infusion of D10W to maintain glucose levels between 101 to 140 mg/dL.
• Additionally, a study from 7 compared the impact of different IV fluids on blood glucose levels in non-diabetic patients undergoing elective major non-cardiac surgeries, finding that Ringer lactate solution may be a suitable alternative for perioperative maintenance.

Key Considerations

• The choice of IV fluid and rate should be individualized based on the patient's specific needs and glucose levels.
• Close monitoring of blood glucose levels is crucial to ensure adequate glycemic control.
• The use of insulin and glucose infusions should be guided by established protocols and guidelines, as highlighted in 3 and 6.
• The selection of IV fluid should take into account the potential impact on blood glucose levels, as demonstrated in 4, 5, and 7.