Nothing by mouth

No, it is not a passive waiting game.

The patient is admitted and strictly made NPO, nothing by mouth, to prepare their gut in case surgery becomes necessary.

They are heavily hydrated with IV crystallides.

You withhold strong narcotic analgesics initially.

The slide explicitly designates the Ochsner-Sharon regimen as a conservative management protocol for this specific presentation.

It mandates absolutely no emergency surgery.

The protocol lists NPO, nothing by mouth, IV fluids, four broad-spectrum antibiotics, analgesics, and strict vital sign monitoring every two hours.

Very strict.

Both ADA and the Endocrine Society recommend basal bolus insulin as the preferred regimen for non-critically ill patients who are eating.

Now what about patients who are not eating? Fasting or NPO patients? That requires a different approach.

For NPO patients, the basal insulin component is retained or reduced depending on the clinical situation, but mealtime bolus insulin is held or minimized.

The key is to not abruptly stop all insulin in patients with type 1 diabetes or insulin-dependent type 2 diabetes, as even without eating they have a baseline insulin requirement.

Correction insulin can be given every 4 to 6 hours based on glucose checks.

I've never seen that.

Have any of you ever seen that? Yeah, patients that are NPO

in the hospital for whatever reasons, and you'll check your urine sodium, and the urine sodium is low, and you're like, I really think it's SIADH.

They get some saline because everybody else thought it was volume depletion, and all of a sudden that urine sodium shoots back up.

That is such a hard thing to combat, people assuming that just because somebody's been NPO, they must be volume depleted.

He's been NPO for the surgery today, so he must be volume down.

You're like,

for 12 hours? You think somebody's volume depleted for 12 hours of being NPO?

And you hear them in the hospital all the time.

But I had my first patient ask, what does NPO mean? You may get, I can't eat, but MPO means way more than that.

Actually, it means nil per os, which means nothing by mouth.

And the reason we use it usually is not because we're trying to make the patient hungry.

Oral intake needs to be restricted, commonly because of a procedure going to happen, anesthesia, sedation, or intervention may be coming about, okay? And what counts as a.k.a.

nothing can depend on that particular order, right? Like foods, liquids, medications, candy, or other oral intake may be treated differently depending on the clinical situation.

One of the most important questions a patient can ask is, what exactly am I allowed to have, okay? Now, I don't think people really understand that it's very important to follow this instruction, but why do we make people NPO? The major concern is because of pulmonary aspiration.

So normally, your body has several defense mechanisms that are protecting their lungs.

Mm.

Start four V fluids, TPN, keep them NPO.

And the repair is often staged using a Vicryl mesh silo.

Right.

Submucosa looks foamy, muscularis looks linear.

Initial management is non-operative.

NPO, antibiotics, TPN, and serial abdominal exams.

Right, the strict NICU protocol.

You can also utilize an octreotide drip to globally decrease splanchnic blood flow.

If they continue to leak, you escalate to making them completely NPO and starting total parenteral nutrition.

If all conservative measures fail after several weeks, you must use a lymphangiogram or lymphoscintigraphy to map the exact location of the leak and take them to the OR for surgical ligation.

The next major complication of the failing liver is hepatic encephalopathy.