All the above replies are
intellectually stimulating.
They're also KINDA MEANINGLESS when it comes to NPO guidelines.
We're all in the game.
We all know the ASA guidelines and are taught,
CULT LIKE, to recite them.
LIVE THEM.
Like some
JIM JONES CYANIDE KOOL AID PARTY.
And yet if one
REALLY analyzes the literature we have on NPO guidelines
or if you're like me, lucky to have several analytical buddies who have the ability to decipher esoteric statistical data, one realizes the
weakness of said studies.
then one considers additional cynicism.....the recent HUGE ANESTHESIA ACADEMIC STUDY SCANDALS...
http://www.anesthesiologynews.com/index.asp?section_id=3&show=dept&ses=ogst&issue_id=486&article_id=12634......which allows one to say to themselves....
"wow......I've been in practice for a LONNNNNNG time following the literature......BUT......UHHHHHHH....my VAST clinical experience CONTRADICTS the literature....
AND THEN you consider
YOUR personal experience with
thousands and thousands of successful anesthetics.....with
many, many "judgement calls" made with
no deleterious sequelae...
All the above considered, I've come to the personal conclusion that
OUR NPO GUIDELINES ARE STUPID. ITS ONLY BECAUSE OF LITIGINOUS FEAR THAT MOST ANESTHESIOLOGISTS WHEN CONFRONTED WITH A "SOFT CALL" NPO ISSUE DEFER TO OUR STUPID NPO GUIDELINES.
Can't blame them for deferring.
Deferral of a case, though, because of a "soft" NPO call costs EVERYONE benjamins.
The hospital.
The surgeon.
The anesthesiologist.
The patient.
Think it really matters if a healthy patient drank a cup of creamed coffee on the way to the hospital, or even ate a light breakfast?
I don't, assuming you're astute enough to minimize gastric insufflation on induction....like....
uhhhhh....pre O2, push 200mg propofol, wait for apnea, slam in the LMA #4, gentle ventilation until the dude starts breathing on his own or something similar....
Think it matters if a parturient for a C section ate a full meal five hours ago and she shows up for an elective C section? Think you need to wait for the "magic" eight hour mark?
I don't. She's a full stomach already as far as I'm concerned so a
Junior Whopper with cheese five hours ago shouldnt make a difference.
I could go on and on.
The case Plank is talking about includes
alotta stomach insufflation though, so considering that I'd probably defer. I recently posted a GI bleed case where I was glad I intubated the chick since the GI dudes gastric insufflation brought all the old blood that was sitting in the stomach
UP AND OUTTA HER MOUTH like some horror movie.....
Aside from GI cases that require gastric insufflation, though, I'll continue to say that
OUR NPO GUIDELINES ARE WAAAAAAAAAAY TOO PROTECTIVE.
Yeah, yeah, I know.
Theres f u kking personal injury lawyers every where in this country which means we're putting ourselves at risk legally if we practice outside our "all knowing academic guru's" studies.
I'm not asking you to practice outside the guidelines.
What I will do, though, is educate you on when to be
REALLY CONCERNED......what clinical presentations/scenerios/situations when you should
cancel/do an RSI/avoid an LMA.
OK.
Wait for it,
Wait for it....
JET'S SERIOUSLY SERIOUS NPO ISSUES 101 (I think this is a 4 credit undergraduate class at the U of Phoenix)
IF YOU SEE ANY OF THE STUFF LISTED BELOW, WORRY. REALLY WORRY. ABOUT ASPIRATION RISK, and protect the patient with 1)a little reverse trendelenberg when inducing 2)rapid sequence induction with no ventilation and CDAZY FAST insertion of an endotracheal tube 3)Selleck maneuver if you're so inclined but I don't think it makes a difference
1) Anyone with a
true abdominal pathophysiologic state.....appendicitis, small/large bowel obstruction et al
2) Anyone with
TRUE reflux......
JESUS H, DUDES, "reflux" is a diagnosis like ADD.
ITS EVERYWHERE! Most patients when queried, though, deny
POSTURAL SYMPTOMS. And
therein lies the key to giving anesthetic-concern-altering-info.....WHETHER OR NOT THE PATIENT HAS POSTURAL GERD. Does the patient have GERD symptoms when they lie flat, and have had to alter their lifestyle (incline the head of their bed to sleep, missing a PPI dose results in misery, etc) to accomodate?
Then you need to worry. People with "GERD" who don't experience these kinda scenerios can be mask ventilated/LMAed IMHO.
3) Healthy patient who ate a
TRUE MEAL (eggs, Popeyes biscuit, sausage) within the last
2 hours. Don't misunderstand me. I cancel the cases involving the satiated patient just like you do for the elective knee scope. What I
AM saying, though, is if we practiced in a non-litiginous nation, I'm confident I could put an LMA in a healthy dude that showed up for a knee scope that ate a full meal three hours ago. And do it safely.
4) Anyone with
TRUE GASTROPARETIC issues. This does not include
every diabetic/renal patient.
5) Trauma patients. God only knows what these people have done before they arrived.
OK. Thats a good start to the
TRUE NPO ISSUES.
I.E. NPO issues when you should
REALLY WORRY as opposed to
fearing getting sued for ignoring our "guidelines."
I'd enjoy your additions to my starting-list.
