Limits of NPO restrictions

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drrosenrosen

drrosenrosen

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So here we are:

25 y/o male, h/o UC s/p colectomy w/ J pouch. In for a strictureplasty. It'll take 30 minutes - I was planning on popping in an LMA and giving him some Sevo to breathe. Then he says that he had "a sip" of juice at 0700. So I explain that honesty is important to avoid aspiration and death, he assures me it was just a sip of V8 with his vitamin at 7am, no other po intake all day. It's now 1400. Did he buy himself a tube +/- RSI, or is it safe to proceed with LMA? I'll tell you what I did after some people weigh in.
 
I think that 7 hours NPO is more than adequate- especially when last intake was a sip of juice. If you think LMA/SEVO is the best plan for this patient then I wouldn't let the V8 stop you.
 
Assuming abscense of bowel obstruction, Yup, I agree. 6 hours is my limit for liquids and light meals. 8 hours if it was a fatty meal (double bacon cheese burger with fries).

I would also give him some Reglan, pepcid, and Bi-citra.
 
rmh
I know you are worried about aspiration (as we all are) but I would give a 2nd thought to giving a UC patient reglan- usually they are hyperactive to begin with and I would be worried about any hazards that may be associated with a potential obstruction/ exacerbation of underlying disease vs the possibility of there being a significant amount of fluid in the stomach after 7 hours to cause a problem- also if I am that worried he may be obstructed, no LMA and also no reglan.
I have no data to back up this opinion but I have found a lot of UC pt's to be squirrelly at baseline, with reglan's potential psych effects- its another reason I wouldn't use it on this particular patient. Agree with pepcid, bicitra I am not a big fan of especially if I'm obtunding reflexes and not protecting the airway- although I have seen plenty of OB patients empty their own stomachs after getting a 30 cc shot of the stuff- so I guess it has some benefit!!
 
drrosenrosen said:
So here we are:

25 y/o male, h/o UC s/p colectomy w/ J pouch. In for a strictureplasty. It'll take 30 minutes - I was planning on popping in an LMA and giving him some Sevo to breathe. Then he says that he had "a sip" of juice at 0700. So I explain that honesty is important to avoid aspiration and death, he assures me it was just a sip of V8 with his vitamin at 7am, no other po intake all day. It's now 1400. Did he buy himself a tube +/- RSI, or is it safe to proceed with LMA? I'll tell you what I did after some people weigh in.
Click to expand...

I understand that you are concerned that he might be lying to you and not telling you that he just had a Big mac and a milk shake on his way to the hospital, is that what it is?
If he is an adult and competent you have to believe him, and assume that all he had was that juice and it's gone by now.
 
The sip of V8 wouldn't affect my anesthetic plan:

You can give bicitra if you feel like making your patient vomit. Otherwise, for this instance, I'd skip it.

Reglan will be worthless for induction, takes 20-30 minutes to have any effect.

Pepcid also worthless for induction. See above.

If you REALLY felt like there will be an issue here then a pro-seal will let ya skip the tube for sure.
 
VentdependenT said:
The sip of V8 wouldn't affect my anesthetic plan:

You can give bicitra if you feel like making your patient vomit. Otherwise, for this instance, I'd skip it.

Reglan will be worthless for induction, takes 20-30 minutes to have any effect.

Pepcid also worthless for induction. See above.

If you REALLY felt like there will be an issue here then a pro-seal will let ya skip the tube for sure.
Click to expand...


Reglan takes 1-3 minutes to do its job. It is very fast. Pepcid needs 30-45 minutes to reduce gastric acid levels. I am not arguing you need either of these agents.

Blade
 
BLADEMDA said:
Reglan takes 1-3 minutes to do its job.
Blade
Click to expand...

It is my understanding that reglan IV is pretty fast. ~5 min.

Did you ask him what kind of juice? What if it was one of those OJ "No Pulp". Is that a clear liquid? What if he had the one with calcium?- Not a clear liquid. You never know.
 
drrosenrosen said:
In for a strictureplasty.
Click to expand...

I would consider him high risk for aspiration just for having a stricture. I don't think you can warranty normal GI transit time in such situation.
 
so we all know not to give reglan to a pt with bowel obstruction. But have any of you seen any studies proving this? I doubt that there are any since you can't get people to consent to a study that theoretically will cause bowel perforation. I doubt it would do anything.
 
Noyac said:
so we all know not to give reglan to a pt with bowel obstruction. But have any of you seen any studies proving this? I doubt that there are any since you can't get people to consent to a study that theoretically will cause bowel perforation. I doubt it would do anything.
Click to expand...
There was a time in other parts of the world when Reglan was used extensively as a pure anti emetic, regardless of the cause, and with double the current U.S. dose (20mg).
No one really worried about that theoretical risk, and I am sure it will be very easy to do meta analysis on these cases and come up with the conclusion that it doesn't matter if you had obstruction or not.
 
So I did just that. LMA, sevo. No bicitra, reglan, or pepcid. His stricture was at the ileoanal anastomosis, so it wasn't affecting his gastric emptying. My question, I guess, was more this: I felt that it was totally safe. But if he'd had a bad outcome of any kind, I could see a lawyer keying on any deviation from practice guidelines. "Dr Rosenrosen, are you aware of the ASA's guidelines on NPO? Was this patient NPO for 8 hours before surgery?" How worried do you have to be about this kind of piddly s h i t in the real world, from a medicolegal standpoint?
 
Isnt the current recomendation for light meals 6 hours?
 
drrosenrosen said:
So I did just that. LMA, sevo. No bicitra, reglan, or pepcid. His stricture was at the ileoanal anastomosis, so it wasn't affecting his gastric emptying. My question, I guess, was more this: I felt that it was totally safe. But if he'd had a bad outcome of any kind, I could see a lawyer keying on any deviation from practice guidelines. "Dr Rosenrosen, are you aware of the ASA's guidelines on NPO? Was this patient NPO for 8 hours before surgery?" How worried do you have to be about this kind of piddly s h i t in the real world, from a medicolegal standpoint?
Click to expand...

The LMA is fine with this patient, but you're still second-guessing yourself. If you're really that worried about it, pop in an ETT. It might be overkill, it might not, but it's certainly not wrong in this case. It would be much easier to defend your position to intubate someone than argue the nuances of NPO restrictions and gastric-emptying times with a friggin' attorney.
 
drrosenrosen said:
So here we are:

25 y/o male, h/o UC s/p colectomy w/ J pouch. In for a strictureplasty. It'll take 30 minutes - I was planning on popping in an LMA and giving him some Sevo to breathe. Then he says that he had "a sip" of juice at 0700. So I explain that honesty is important to avoid aspiration and death, he assures me it was just a sip of V8 with his vitamin at 7am, no other po intake all day. It's now 1400. Did he buy himself a tube +/- RSI, or is it safe to proceed with LMA? I'll tell you what I did after some people weigh in.
Click to expand...

Personally, I would have done LMA, because I use six hours for light meal and I hardly call a sip of V8 a meal at all.

However, if I was considering doing an RSI because I was concerned about that theoretical magic eight hours not being reached, I would have just waited that extra hour and have an official NPO status. Because if this isn't an emergent procedure and he barfs at 7.5 hours with an RSI, then you are still in trouble. To me, I do RSI if it is emergent and can't wait eight hours (or six, depending on what you believe) or if the patient has some reason to have a 'full stomach' no matter what the NPO status (in labor).
 
uuggghhh...aspiration is overrated as a risk....

and it has become a vicious cycle between us and the damn lawyers......with the only people REALLY sufferring being the patients.

They sue because of adverse events unrelated to NPO status...we pinch our sphincters...and do all this reglan, pepcid, bicitra none sense......

then the lawyers see us doing this nonsense...so therefore it must be something we can prevent.....

and the cycle goes on.....

myths are perpetuated...

cases get cancelled unncessarily....

patients get exposed to meds unnecessarily...

blah blah blah....

patient safety.....not changed one single iota.
 
militarymd said:
uuggghhh...aspiration is overrated as a risk....

and it has become a vicious cycle between us and the damn lawyers......with the only people REALLY sufferring being the patients.

They sue because of adverse events unrelated to NPO status...we pinch our sphincters...and do all this reglan, pepcid, bicitra none sense......

then the lawyers see us doing this nonsense...so therefore it must be something we can prevent.....

and the cycle goes on.....

myths are perpetuated...

cases get cancelled unncessarily....

patients get exposed to meds unnecessarily...

blah blah blah....

patient safety.....not changed one single iota.
Click to expand...

You are absolutely right, and this vicious cycle is in everything we do:
Routine labs, Transfusion thresholds, doing more documentation than patient care.....


This is how medicine is practiced in this country and it's not going to get better.
 
VentdependenT said:
You can give bicitra if you feel like making your patient vomit. Otherwise, for this instance, I'd skip it.
Click to expand...

agreed. remember, if you give them 30mL of bicitra, you've just put something into their stomach.
 
Planktonmd said:
You are absolutely right, and this vicious cycle is in everything we do:
Routine labs, Transfusion thresholds, doing more documentation than patient care.....


This is how medicine is practiced in this country and it's not going to get better.
Click to expand...

"The People" ask for this treatment by permitting abuse of the legal system. It will continue because the lowest common denominator is that people should be allowed to sue for unlimited dollars for any medical complication that was potenially preventable. This is clearly not what's best for society in general (unnecessary expenses, meds, labs, procedures, etc..), but

we don't live in a "what's best for society" country.

Our country is mostly all about "what's best for the individual" (when it's not "what's best for corporate America"- isn't it interesting how that kind of breaks things down to Democrat vs. Republican?). I digress...

This is particularly notable if the 'individual' is rich, or has some element of power, including an a**hole lawyer willing to exploit the ASA NPO guidelines to make a few bucks.

A no-fault medical malpractice insurance system would fix some of these problems. But in this country, that would be a RADICAL IDEA.

I thought I'd try a little of Jet's posting style for kicks..
 
powermd said:
"The People" ask for this treatment by permitting abuse of the legal system. It will continue because the lowest common denominator is that people should be allowed to sue for unlimited dollars for any medical complication that was potenially preventable. This is clearly not what's best for society in general (unnecessary expenses, meds, labs, procedures, etc..), but

we don't live in a "what's best for society" country.

Our country is mostly all about "what's best for the individual" (when it's not "what's best for corporate America"- isn't it interesting how that kind of breaks things down to Democrat vs. Republican?). I digress...

This is particularly notable if the 'individual' is rich, or has some element of power, including an a**hole lawyer willing to exploit the ASA NPO guidelines to make a few bucks.

A no-fault medical malpractice insurance system would fix some of these problems. But in this country, that would be a RADICAL IDEA.

I thought I'd try a little of Jet's posting style for kicks..
Click to expand...


Yeah, I'd say that pretty much sums it up unfortunately.
 
powermd said:
A no-fault medical malpractice insurance system would fix some of these problems. But in this country, that would be a RADICAL IDEA.

I thought I'd try a little of Jet's posting style for kicks..
Click to expand...

Can you go further into what a no-fault medical malpractice insurance system is?

Nice posting style by the way.
 
rmh149 said:
Can you go further into what a no-fault medical malpractice insurance system is?

Nice posting style by the way.
Click to expand...

Here is a good article on no-fault med-mal:

http://memag.com/memag/article/articleDetail.jsp?id=108942

The short version goes something like this:

Doctors pay into a fund for compensation of patients injured by medical mistakes and malpractice.

When an error occurs, small or large, the doctor acknowledges the error to the patient, and initiates a compensation claim. The claim goes before a medical/legal/judiciary board to assess reasonable compensation for the error, and the patient gets paid. Doctors benefit by learning from others mistakes.

None of this money goes to laywers. Making more $ available to patients, and saving the system money.

Similar claims get compensated with similar $$.

More patients get compensated, even those with claims too small to attract a lawyer.

Credit to Jet for his OUTRAGEOUS and FLAMBOYANT style..
 
BLADEMDA said:
Reglan takes 1-3 minutes to do its job. It is very fast. Pepcid needs 30-45 minutes to reduce gastric acid levels. I am not arguing you need either of these agents.

Blade
Click to expand...


Surely you don't believe that reglan enhances gastric emptying within 3 minutes. It may begin to have an effect within that time frame, but can't possibly significantly change gastric volumes in a few minutes (or maybe ever-- the data isn't great). This is really semantics-- oral reglan takes 20-30 minutes for onset time and iv is very quick, but time to onset and time to any kind of clinically important difference must be longer than that.

I dont use the stuff at all.
 
powermd said:
Here is a good article on no-fault med-mal:

http://memag.com/memag/article/articleDetail.jsp?id=108942

The short version goes something like this:

Doctors pay into a fund for compensation of patients injured by medical mistakes and malpractice.

When an error occurs, small or large, the doctor acknowledges the error to the patient, and initiates a compensation claim. The claim goes before a medical/legal/judiciary board to assess reasonable compensation for the error, and the patient gets paid. Doctors benefit by learning from others mistakes.

None of this money goes to laywers. Making more $ available to patients, and saving the system money.

Similar claims get compensated with similar $$.

More patients get compensated, even those with claims too small to attract a lawyer.

Credit to Jet for his OUTRAGEOUS and FLAMBOYANT style..
Click to expand...

This System will never work unless you completely take away the possibility of civil litigation against doctors, which is never going to happen.
You have to remember that law suits are equivalent to winning the Lotto for many patients and if they can give it a shot they will.
 
powermd said:
The web site seems designed to inflict pain on visitors. How is the PA system implemented, and why is it a disaster?
Click to expand...

first, see plankton's comments above.

second, read this:

http://www.mcare.state.pa.us/mclf/lib/mclf/about_mcare.pdf

each year, doctors are forced to pay into a system, which doesn't prevent, or really protect the physician from, litigation. there is no choice. and, if you decide you want to leave the state to practice elsewhere, you are also penalized in that you have to pay for that entire year anyway.

mcare was set-up to help pay for catastrophic losses in high-risk specialties. the problem is, even if you are in a low-risk specialty that rarely gets sued (eg., psychiatry), you still have to pay into the system... in addition to carrying other basic malpractice insurance.

the result? it's lose-lose for some specialties who are unfairly penalized for choosing to practice in pennsylvania (which is, among many other things, part of the reason why i'm leaving to practice in another state).

what we need is tort reform, not some extra set of deep pockets for lawyers to dig into. but, this is what you get when you let lawyers (who make-up the majority of politicians) run government... kinda like letting the inmates run the prison.

this is, in no other terms, double-dipping when it comes to insurance coverage. i would be for such a system if it actually worked and kept insurance premiums under control. it was set-up to provide a mechanism to help doctors keep medmal coverage in the state and at a reasonable cost. until you have tort reform, though, you will not get any meaningful return for this program... just punishment to doctors who don't get sued.
 
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