Do patients with diabetic ketoacidosis (DKA) need to be kept nothing by mouth (NPO)?

Patients with DKA Do Not Need to Be Kept NPO

Patients with diabetic ketoacidosis (DKA) do not need to be kept NPO (nothing by mouth) as a standard practice. When patients are able to eat, they should transition to oral intake with appropriate insulin coverage while continuing treatment for DKA resolution 1, 2.

Management Approach for DKA Patients

Initial Treatment Phase

• Aggressive fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hour is recommended to restore circulatory volume and tissue perfusion 2
• Continuous intravenous insulin infusion at 0.1 units/kg/hour should be maintained until resolution of ketoacidosis, regardless of glucose levels 2, 3
• Electrolytes, particularly potassium, should be monitored and replaced as needed 2, 3

Transition to Oral Intake

• Once DKA is resolving and the patient is able to eat, they should transition to a multiple-dose insulin schedule using a combination of short/rapid-acting and intermediate/long-acting insulin 3
• When transitioning from IV to subcutaneous insulin, administer basal insulin 2-4 hours before stopping the intravenous insulin to prevent recurrence of ketoacidosis 2, 3
• Continue intravenous insulin infusion for 1-2 hours after starting subcutaneous insulin to ensure adequate plasma insulin levels 3

Monitoring During Treatment

• Blood should be drawn every 2-4 hours to determine serum electrolytes, glucose, blood urea nitrogen, creatinine, osmolality, and venous pH 3
• Follow venous pH and anion gap to monitor resolution of acidosis 3
• DKA resolution requires glucose <200 mg/dL, serum bicarbonate ≥18 mEq/L, venous pH >7.3, and anion gap ≤12 mEq/L 3

Special Considerations

If Patient Cannot Eat

• If the patient is NPO due to clinical condition, continue intravenous insulin and fluid replacement, and supplement with subcutaneous regular insulin as needed every 4 hours 3
• For adult patients who are NPO, give 5-unit increments for every 50 mg/dL increase in blood glucose above 150 mg/dL (up to 20 units for blood glucose of 300 mg/dL) 3

Glucose Management During DKA Treatment

• Add dextrose to intravenous fluids when glucose falls below 200-250 mg/dL while continuing insulin infusion to resolve ketosis 3
• Target glucose between 150-200 mg/dL until DKA resolution parameters are met 3

Common Pitfalls to Avoid

• Premature termination of insulin therapy before complete resolution of ketosis can lead to recurrence of DKA 2, 3
• Interruption of insulin infusion when glucose levels fall is a common cause of persistent or worsening ketoacidosis 3
• Inadequate carbohydrate administration alongside insulin can perpetuate ketosis 2, 3
• Failure to monitor and replace electrolytes can lead to complications 2

Evidence-Based Approach

• The American Diabetes Association guidelines do not recommend keeping DKA patients NPO as a standard practice 1
• When patients are able to eat, they should start a multiple-dose insulin schedule while continuing appropriate monitoring 3
• For patients who cannot eat, intravenous insulin and appropriate fluid management should continue until oral intake is possible 3

By allowing patients with DKA to eat when they are able to, while providing appropriate insulin coverage and continuing treatment until resolution of ketoacidosis, clinicians can effectively manage DKA without unnecessarily restricting oral intake.