Black coffee w sugar no cream..npo??

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apma77

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2 cups blk coffee in am of surgery w 4 tea spoons sugar....alrite folks do you treat this as a clear still or go 6 hrs cause of sugar added??

also whats the deal on gum chewing??

apparently asa doesnt deal with these issues so whats the verdict???

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In all seriousness though, I'd treat those as clears. I find that the ASA NPO guidelines are usually not that specific when it comes to the patient who has forgotten to stay NPO (or is too stupid to do so) because this type of patient is diabetic, obese, with a hiatal hernia anyway, and so the guidelines don't say much except use your judgement. That's a GOOD thing. It allows us the flexibility to do what's best without (hopefully) screwed by the lawyers because you didn't follow guidelines to the letter. So if it's not a big surgery, I usually just RSI and move on. Usually. I call this concept, "Too dumb/fat for an LMA."
 
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I just had a patient who was chewing tobacco up until I was ready to wheel him back to the OR -- I couldn't tell even though I looked in his mouth, the RN couldn't tell, my staff didn't notice it until he asked to spit out a wad of tobacco. He said he's done this with all his previous 16 surgeries, and it had never been a problem.

The dude swore that he didn't swallow anything. After discussing with multiple senior staff members, my staff decided to delay the case by 2h.

Would anyone else have gone ahead? We had all sorts of answers from cancel to just treat it like chewing gum.
 
4 hours sounds good to me.
 
I realize I'm in the minority here - but anyone stupid enough to ignore multiple NPO instructions and drinks two cups of coffee on the way to the hospital would get postponed 8 hrs at our place. Why? Because if they drank two cups of coffee, they probably had something to eat with it as well. It's kind of like never being sorry you put in an ETT, but have often been sorry that you didn't. Same concept. I've never been sorry we postponed a case like this, but have been sorry when we caved to pressure from the patient or surgeon to proceed because "I swear I only had coffee".
 
I realize I'm in the minority here - but anyone stupid enough to ignore multiple NPO instructions and drinks two cups of coffee on the way to the hospital would get postponed 8 hrs at our place. Why? Because if they drank two cups of coffee, they probably had something to eat with it as well. It's kind of like never being sorry you put in an ETT, but have often been sorry that you didn't. Same concept. I've never been sorry we postponed a case like this, but have been sorry when we caved to pressure from the patient or surgeon to proceed because "I swear I only had coffee".

OP never indicated what the NPO instructions were. Could have been 2 hours for clears.
 
I realize I'm in the minority here - but anyone stupid enough to ignore multiple NPO instructions and drinks two cups of coffee on the way to the hospital would get postponed 8 hrs at our place. Why? Because if they drank two cups of coffee, they probably had something to eat with it as well. It's kind of like never being sorry you put in an ETT, but have often been sorry that you didn't. Same concept. I've never been sorry we postponed a case like this, but have been sorry when we caved to pressure from the patient or surgeon to proceed because "I swear I only had coffee".


while I respect the quote and have thrown it around myself in the past, when a patient comes back with a vocal cord injury and has to do voice rehab for 6 months postop, I've been sorry they got an ETT instead of an LMA if there was a choice.


black coffee (with sugar) is a clear and 2 hours. I'm not here to teach the patient a lesson. I'm here to keep them safe. And if they are open and honest and can promise they didn't eat anything else, I feel my butt is sufficiently covered for the less than 1/1000 chance of aspiration on induction.
 
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Despite its color, coffee has been branded a clear liquid. Most anesthesiologists would go with the common 2 hr. guidelines for clears which in this case includes black coffee.
 
No it ain't. It's black. You can't see through it. It's an opaque liquid.

I don't think opaqueness makes a liquid a non-clear for NPO purposes. Particulate matter, protein, and fat do.

I wouldn't call pulpy orange juice or milk (even nonfat) a clear, but black coffee, sodas, sports drinks, tea ... all clears and 2 hrs.
 
No it ain't. It's black. You can't see through it. It's an opaque liquid.

Plus if you add sugar, you are certainly stimulating decreased pH and increased gastric volume.

4hrs for me.

Recommendations for Clear Liquids. It is appropriate to
fast from intake of clear liquids at least 2 h before elective
procedures requiring general anesthesia, regional anesthesia,
or sedation/analgesia (i.e., monitored anesthesia care). Examples
of clear liquids include, but are not limited to, water,
fruit juices without pulp, carbonated beverages, clear tea, and
black coffee.

The sugar part doesn't bother me.
 
Despite its color, coffee has been branded a clear liquid. Most anesthesiologists would go with the common 2 hr. guidelines for clears which in this case includes black coffee.

Agree 100%. Orange soda, gatoraid (regular), coke, coffee. All not "clear", but still a clear liquid for NPO purposes. A couple sugar packets don't change anything. Juice is considered a clear and it would have more sugar content than the coffee.
One of our JR faculty also erroneously believed that a "clear" liquid had to be visually clear, so maybe people are teaching that somewhere?
Gum is 2 hours for me as well, as it stimulates saliva secretion which the patient is presumably swallowing. That may be conservative, but it is what I was taught, and was the policy at several hospitals.
 
Gum is 2 hours for me as well, as it stimulates saliva secretion which the patient is presumably swallowing. That may be conservative, but it is what I was taught, and was the policy at several hospitals.

I am pretty sure we have discussed this before. I just have then spit the gum out and proceed forward.
 
I am pretty sure we have discussed this before. I just have then spit the gum out and proceed forward.

Didn't we find that gum chewing decreases gastric volume by promoting gastric emptying? That's assuming the patient didn't swallow the gum when caught.

I suction the stomach of all my cardiac patients before the echo probe goes in. It's amazing how much I get out of some patients who are NPO. I worry more now about the nervous/anxious patients and typically I'll try to intubate those without mask ventilation. Using rocuronium makes it pretty easy.
 
There was a study in the 90's in A&A. Gum increased gastric contents in non smokers. I think it doubled the volume, but it was still only 1-2 oz. I'm not sure it's really clinically significant, that is until the pulm cripple ends up in the ICU overnight and the lawyers start circling. I wait.
 
With my patient population (everyone is diabetic, most have cardioulmonary disease, and Im at an academic center) and our excellent preop clinic who gives clear and detailed instructions, I have been known to cancel these cases/wait 6-8 hours. Probably not the right answer, and maybe a little punitive.
 
"The check is in the mail."

"I won't come in your mouth."

Should this be added to the list?


Well they already admitted they didn't do something they were supposed to. A quick lecture on the dangers of aspiration pneumonia and the possibility of dying tends to get the truth of someone.

And if they didn't? It's their problem, not mine, because I've already documented with witnesses that we are falling within the NPO guidelines. I cannot be held liable for their lying to me.
 
And if they didn't? It's their problem, not mine, because I've already documented with witnesses that we are falling within the NPO guidelines. I cannot be held liable for their lying to me.

How does that argument appeal to the juries that doled out millions of dollars in CP births, when the doc did nothing wrong? It's disheartening, but, considering half of marriages end in divorce, and how many due to cheating or financial malfeasance, which both entail lying to the other party, and the appearances, no matter how much, how well, or how frequently you notify some patients, and you are wholly within the guidelines, the litigious creeps will sue if something goes wrong. "He was so thorough and clear and seemed so nice and professional, I felt intimidated into telling him that I did have a bagel before my surgery", through a raspy voice.

(The marriage reference is an extension of "all patients lie", to "all people lie".) Right now, "Perry Mason" is on the TV; the line "I didn't think it mattered" is used frequently. That is the same thing people have told me in the ED for myriad different conditions.

When I get a patient that is likely going to need Sx or sedation, I clearly tell them "don't eat anything, don't drink anything, don't put anything in your mouth, including ice chips and gum, unless we give it to you. Don't let anybody bring you anything, or say 'just a little, it won't be a problem', because it certainly COULD be a problem", I write the NPO order, and, since I can't stand at the bedside, I still worry that someone is going to get one by me.
 
Sodas I consider clears, so I don't know why I would treat coffee with sugar any different. No protein or lipids that would delay gastric emptying, so I would wait two hours then proceed.
 
How does that argument appeal to the juries that doled out millions of dollars in CP births, when the doc did nothing wrong? It's disheartening, but, considering half of marriages end in divorce, and how many due to cheating or financial malfeasance, which both entail lying to the other party, and the appearances, no matter how much, how well, or how frequently you notify some patients, and you are wholly within the guidelines, the litigious creeps will sue if something goes wrong. "He was so thorough and clear and seemed so nice and professional, I felt intimidated into telling him that I did have a bagel before my surgery", through a raspy voice.

(The marriage reference is an extension of "all patients lie", to "all people lie".) Right now, "Perry Mason" is on the TV; the line "I didn't think it mattered" is used frequently. That is the same thing people have told me in the ED for myriad different conditions.

When I get a patient that is likely going to need Sx or sedation, I clearly tell them "don't eat anything, don't drink anything, don't put anything in your mouth, including ice chips and gum, unless we give it to you. Don't let anybody bring you anything, or say 'just a little, it won't be a problem', because it certainly COULD be a problem", I write the NPO order, and, since I can't stand at the bedside, I still worry that someone is going to get one by me.



It doesn't have to appeal to a jury because it would never get there. You think a patient who lies to everyone they see about not eating anything would have any successful grounds for a suit around an aspiration event? If I treated them within the standard of care, it's irrelevant. Aspiration happens in patients who are NPO. It isn't my job to perform an EGD to assess their stomach contents. It's my job to attempt to induce anesthesia safely. Clear liquid is clear liquid. It doesn't make me treat them like they just ate biscuits and gravy.
 
Every time I see this thread I think of the old Heavy D song. Some of you know what I am talking about. "Black coffee, no sugar no cream, that's the king of girl I need down with my team"

He just died at age 44 BTW. PE I think after a transatlantic flight.

Anyway, I have nothing to contribute really, except per the guidelines, wait 2 hrs.
 
It doesn't have to appeal to a jury because it would never get there. You think a patient who lies to everyone they see about not eating anything would have any successful grounds for a suit around an aspiration event? If I treated them within the standard of care, it's irrelevant. Aspiration happens in patients who are NPO. It isn't my job to perform an EGD to assess their stomach contents. It's my job to attempt to induce anesthesia safely. Clear liquid is clear liquid. It doesn't make me treat them like they just ate biscuits and gravy.


If the little voice in my head tells me the patient isn't being 100% honest about their pre-op NPO status I'll give them a brief description of the slow and miserable death which potentially awaits them after they aspirate. More time than I can count I've had patients 'fess up in their pre-op holding cubicle about the "one little piece of toast" they had before coming to the hospital.
 
If the little voice in my head tells me the patient isn't being 100% honest about their pre-op NPO status I'll give them a brief description of the slow and miserable death which potentially awaits them after they aspirate. More time than I can count I've had patients 'fess up in their pre-op holding cubicle about the "one little piece of toast" they had before coming to the hospital.

that's very similar to my approach. A nice description of aspiration pneumonia and being on the vent in the unit tends to get their attention.
 
I did a D&C once in the middle of the night my CA1 year. 20 year old, skinny easy airway 5 minute case.
Spoke to the patient, perfunctory airway exam ect.
Took her back, propofol LMA4# no problems. Within a few minutes we noticed huge amount of secretions despite the glyco. We suctioned her out through the LMA and would have tubed but the case was over.
I pull out the LMA and theres a huge wad of gum on the side of the LMA.
Somehow the OB team, my attending, my senior resident, myself, and the circulator nurse missed the fact that she had gum in her mouth (then again, it was like 4am and we've been working non-stop) .
Anybody else ever have this happen?
 
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