What is the best fluid to administer to a diabetic patient who is Nil Per Os (NPO)?

From the Guidelines

For a diabetic patient who is NPO, the best intravenous fluid is typically lactated Ringer’s or normal saline solution, as recommended for severe dehydration or altered mental status 1. This approach prioritizes hydration and electrolyte balance, which is crucial for diabetic patients who cannot take oral nutrition or medications. The choice between lactated Ringer’s and normal saline solution should be based on the patient's individual needs and laboratory results. Key considerations include:

• Regular blood glucose checks should be performed every 1-2 hours initially, then every 4-6 hours once stable, with a target range of 140-180 mg/dL for most hospitalized patients.
• Insulin therapy should accompany fluid administration, typically as a basal-bolus regimen with correction doses based on blood glucose readings.
• Potassium levels should be monitored closely, maintaining levels between 4.0-5.0 mEq/L, with supplementation added to IV fluids as needed, to prevent hypokalemia and related complications.
• The initial infusion rate should be adjusted based on the patient's weight, cardiovascular status, and blood glucose monitoring, to prevent excessive fluid shifts and maintain optimal hydration. It is also important to note that the treatment of hypoglycemia requires ingestion of glucose or carbohydrate-containing food, and glucose is the preferred treatment, although any form of carbohydrate that contains glucose may be used 1. However, in the context of a diabetic patient who is NPO, intravenous fluids are the primary means of hydration and electrolyte management. Overall, the goal is to provide a balanced approach that maintains hydration, electrolyte balance, and blood glucose control, while preventing complications such as ketosis, hypoglycemia, and hypokalemia.

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 best fluid to give a diabetic patient who is NPO (nothing by mouth) is 0.9% sodium chloride. This is because it is the recommended infusion fluid for intravenous use of Humulin R U-100, as stated in the drug label 2.

From the Research

Fluid Administration for Diabetic Patients who are NPO

• For diabetic patients who are NPO (nothing by mouth), the choice of fluid administration is crucial to manage their blood glucose levels and prevent complications.
• According to a study published in 2014 3, oral and intravenous fluids were equally efficacious in lowering blood glucose levels in stable hyperglycemic patients.
• However, another study published in 2006 4 found that using dextrose-containing fluids, such as 5% dextrose in 0.9% normal saline, can cause significant hyperglycemia in non-diabetic patients undergoing elective surgery.
• For diabetic patients who are NPO, it is recommended to use non-dextrose-containing crystalloids, such as lactated Ringer's solution or 0.9% normal saline, as the initial intravenous replacement fluid.
• A study published in 2024 5 found that using lactated Ringer's solution instead of normal saline as the default resuscitative fluid in the management of diabetic ketoacidosis (DKA) resulted in shorter time to resolution of DKA and reduced duration of DKA protocol insulin drip.
• Another study published in 2024 6 found that lactated Ringer's solution was associated with faster time to high anion gap metabolic acidosis resolution compared to normal saline in the acute management of DKA.

Recommended Fluids

• Lactated Ringer's solution
• 0.9% normal saline
• Avoid using dextrose-containing fluids, such as 5% dextrose in 0.9% normal saline, as they can cause hyperglycemia.

Considerations

• The choice of fluid administration should be individualized based on the patient's specific needs and medical condition.
• It is essential to monitor the patient's blood glucose levels and adjust the fluid administration accordingly.
• The use of insulin and other medications should be considered in conjunction with fluid administration to manage the patient's blood glucose levels.