How do you manage patients who are nothing by mouth (NPO) in terms of nutrition and hydration?

Management of NPO Patients: Nutrition and Hydration

Keep all patients NPO only when medically necessary, and for the shortest duration possible—prolonged NPO status without nutritional support leads to rapid deterioration, particularly in older adults and malnourished patients. 1

Initial Assessment and Duration Considerations

Dysphagia Screening (Critical First Step)

• All stroke patients must remain NPO until dysphagia screening is completed within 4-24 hours by a trained nurse 1
• If dysphagia screening is failed, consult speech-language pathology for formal assessment and management plan 1
• Even patients deemed NPO for dysphagia must swallow >500 mL of saliva daily, which itself poses aspiration risk 1

Time-Based Decision Points for Nutritional Support

• If oral/enteral intake is expected to be impossible for >3 days, or <50% of energy requirements for >1 week, initiate parenteral nutrition (PN) 1
• Do not wait for severe malnutrition to develop—early intervention is more effective 2
• Prolonged NPO (≥3 days) without nutritional support is inappropriate in most clinical scenarios 3

Hydration Management

Intravenous Fluid Administration

• Administer isotonic intravenous fluids (normal saline 0.9%) at 70 mL/hour for maintenance hydration 4
• Avoid hypotonic fluids as they contribute to electrolyte imbalances 4, 5
• Monitor urine output (target ≥1-2 mL/kg/hour) and serum electrolytes at least daily 5

Special Populations

• In patients with cardiac or renal dysfunction, be cautious with fluid administration to avoid volume overload 4
• Replace ongoing losses (nasogastric output, drain losses) milliliter-for-milliliter with isotonic saline in addition to maintenance fluids 5

Nutritional Support Strategies

Parenteral Nutrition Initiation

PN is indicated when the gastrointestinal tract is not accessible or functional, and should be started within 48 hours in malnourished patients 6

Energy and Protein Targets

• Energy: 25-30 kcal/kg body weight per day 2, 5
• Protein: 1.2-1.5 g/kg body weight per day (3-4 g/kg in critically ill infants) 2, 5
• Lipids should provide 20-30% of total calories 5

Monitoring Requirements

• Blood glucose monitoring at least daily while on PN 5
• Serum electrolytes (sodium, potassium, magnesium, phosphate) monitored daily initially 5
• Complete micronutrient supplementation from day 1 of PN 5

Refeeding Syndrome Prevention (Critical)

In malnourished patients, start nutritional support early but increase gradually over the first 3 days to prevent refeeding syndrome 1, 2

• Monitor and supplement phosphate, magnesium, potassium, and thiamine even with mild deficiency during first 3 days 1, 2
• This is particularly critical in severely malnourished patients who have been NPO for extended periods 1

Enteral Nutrition Considerations

When to Use Enteral Routes

• Enteral nutrition (EN) is preferred over PN when the gastrointestinal tract is functional 1, 6
• Hold tube feeding in patients with ileus until bowel function returns 4
• Nasogastric tubes are appropriate for short-term feeding; consider PEG for anticipated long-term needs 1

Maintaining Oral Intake During Tube Feeding

• Tube-fed patients should be encouraged to maintain oral intake as far as safely possible 1
• Oral intake provides sensory input, swallowing training, and improved quality of life 1
• Texture-modified foods should be offered based on dysphagia assessment 1, 2

Ethical and Clinical Decision-Making

When NOT to Provide Artificial Nutrition/Hydration

EN, PN, and hydration are medical treatments, not basic care, and should only be used when there is realistic chance of improvement or maintenance of quality of life 1

• Do not initiate in terminal phase of life (expected death within weeks) 1
• Do not use in advanced dementia or terminal malignancy where comfort is the priority 1
• Never use pharmacological sedation or physical restraints to enable EN or PN 1

Voluntary Refusal

• Competent patients may voluntarily refuse nutrition and hydration, which is legally and medically acceptable in end-of-life situations 1
• Adequate comfort care must be provided to these patients 1

Specific Clinical Scenarios

Gastric Outlet Obstruction

• Treatment options include endoscopic stenting, gastrojejunostomy, or venting gastrostomy for decompression 1
• Feeding tubes (gastrostomy for distal obstruction, jejunal for proximal) may be necessary for nutrition 1

Partial Small Bowel Obstruction

• NPO may not be necessary in adhesive partial obstruction—oral medications with laxatives and digestants can decrease need for surgery 7
• Standard NPO with IV hydration and nasogastric decompression remains appropriate for complete obstruction 7

Hip Fracture Patients

• Offer oral nutritional supplements (≥400 kcal/day with ≥30g protein) rather than overnight enteral feeding 1
• Supplementary overnight EN is poorly tolerated and not recommended unless other indications exist 1

Common Pitfalls to Avoid

• Do not keep patients NPO "just in case" without clear medical indication—this practice is common but inappropriate in >30% of cases 3
• Do not use hypoalbuminemia alone as marker for protein malnutrition (affected by inflammation) 2
• Do not restrict energy intake in malnourished patients, even those with obesity 2
• Avoid restrictive diets that limit intake in malnourished patients 2
• Do not delay nutritional consultation—compliance with nutrition team recommendations is often poor (40%) 3

Monitoring and Reassessment

• Reassess NPO status daily—is it still medically necessary? 3
• Monitor for signs of dehydration: decreased urine output, elevated BUN/creatinine, poor skin turgor 4, 8
• Monitor for malnutrition: weight loss, decreased muscle mass, functional decline 8
• Regular dietitian review is essential for enterally-fed patients 8
• Adjust nutritional support based on clinical response and tolerance 6