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NPO for Epidural (or not)...

Discussion in 'Anesthesiology' started by doctor712, 02.27.09.

  1. doctor712

    doctor712

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    I called and made an appointment today for my father to visit his Pain doc for his second round of epidurals. Set the appointment and asked if he should be NPO prior to procedure and was told, "No, Dr. X doesn't require it." My friend, the assistant continues, "Dr. Y requires it, but not Dr. X."

    Ok, well I've shadowed both Drs. Y and X. Both GREAT guys!

    Dr. X, who does NOT require NPO for a Lumbar Epidural is a PM&R physician.
    Amazingly skilled Navy guy who did a fellowship in Spinal Injections...

    Dr. Y, is an Anesthesiologist, requires NPO prior to his Lumbar Epidurals.
    He's a Pain Fellowed anesthesia MD ( I think he studied in NY with Hadzic) who is doing pain patients 4X a week, OR 1X a week.

    I've seen both give epidurals ad infinitum. pretty similar techniques, Dr. Y likes to bend the end of his Touhy (sp?) for guidance before he checks and checks for placement.

    So, my questions:

    a) does this difference in NPO requirement surprise anyone?

    b) if so, why?

    c) what is the board answer to this situation? (NPO or not, for elective lumbar Epidural)

    d) why does everyone think PM&R doc does NOT require NPO, whereas regional Anesthesia dude does?

    e) what is Dr. Y thinking here? if I need to intubate for whatever reason, i'd rather not have a full stomach? than, WHY doesn't Dr. X feel this way as well?

    Discussion time...

    D712
  2. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    I think that you should not ask for medical advice on this forum and that the best thing you could do is to talk to both doctor X and doctor Y and see what their reasoning is for each approach.
    Good luck.
  3. doctor712

    doctor712

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    this wasn't in regard to my father being the patient at all, plankton, i could've left that initial part off actually.

    was really curious as to the training and logic behind NPO for epidural.

    dad part was completely anecdotal. he'll be seeing doc x in a week regardless.

    sorry if this seemed like a medical advice question, i don't EVER ask those here - hopefully this is apparent to all i've threaded to here - and this was simply one of my anesthesia questions.
    i suppose my error was sharing the situation that made me think of this clinical question.

    so, ill respectfully leave this thread with your reply.

    d712
    Last edited: 02.27.09
  4. Planktonmd

    Planktonmd Moderator Emeritus Lifetime Donor

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    You really don't need to be NPO for a steroid epidural injection but if you had some wierd reaction and you required CPR then having an empty stomach would be desirable by most smart people.
    This is where the Anesthesiologist is coming from in requiring NPO and this is why the PMR guy does not require it because he probably never heard of it.
    Anesthesiologists by training and nature are more concerned about making sure that every possibility no matter how rare it is is covered.
  5. doctor712

    doctor712

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    thanks, plank.

    d712
  6. pgg

    pgg Laugh at me, will they? Moderator

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    I disagree; we don't require people to be NPO to get vaccinations, or a Z-pak, or IV morphine, or a spoonful of peanut butter, or any number of things that could cause a weird reaction / anaphylaxis and circ arrest requiring CPR.

    For a steroid only epidural (for which you're not going to sedate the patient) there's no reason for the patient to be NPO.

    At our pain clinic we usually sedate people before sticking them. We tell everyone to be NPO ... but if they forget and eat a Snickers bar on the drive in we'll still do the injection if they're willing to forgo any sedation. Most people who live with chronic pain can tolerate a caudal or lumbar ESI just fine without a hit of propofol or midazolam.

    One could argue that ESIs that include some local anesthetic mixed in with the steroid carry the risk of a high spinal from an inadvertent intrathecal injection ... and those patients ought to be NPO. For a steroid only injection though - I see no significant risk that could be reduced by requiring the patient to be NPO.
  7. doctor712

    doctor712

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    Interesting. You mentioned that for a steroid only injection you really don't need to be NPO, but I've seen patients ask for sedation right there on the table belly down, so, I suppose Dr. Y would have no problem with this. With him, all are NPO. And I've actually seen him watching the monitors and calling out to his nurse, "2 and 1", and I know that is sedation (I asked). I guess another reason these guys do it differently, other than very different training (physiatry vs anesthesia), is because Dr. X may not use any local in his needle, as you mentioned PGG.

    Well, I hope to hear more on this discussion.

    D712
  8. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    More than likely the Anesthesiologist sedates his pain patients much more frequently and much deeper than the PM&R pain doc. Hence NPO status.

    Having trained in both PM&R and Anesthesia, there is massive difference in the level of sedation used, in general.

    In Seattle, some anesthesia pain docs are using Propofol for pain procedures.

    Of course there are exceptions.
  9. Idiopathic

    Idiopathic Newly Minted Lifetime Donor

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    sedation->NPO
    no sedation->no NPO
  10. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Sedation for pain procedures is voodoo. Just because it is someone's preference and "standard", does not make for good medicine.

    If a patient needs sedation for an epidural- they need Psych and not Pain.
    If a patient needs sedation for MBB- then they need a new pain doc.
  11. pgg

    pgg Laugh at me, will they? Moderator

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    I agree, a very large % of pain patients DO need psych. Lots of them need a psych doc more than they need a pain doc.
  12. jwk

    jwk AA-C ASA-PAC Contributor

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    "Pain procedures" runs a wide gamut from simple LESI's to implantable stimulators and everything in between. Some are easily performed without sedation, some couldn't be managed without it.
  13. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Yeah, I know. Overstated. I sedate SCS, disco, and vertebroplasty cases.
    I'll sedate an RF 1-2x per year. Never for esi, mbb, sij.
  14. IN2B8R

    IN2B8R Junior Member

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    Amen! :thumbup:

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