NPO Guidelines: Fact or Fiction?

[BLADEMDA]

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NPO guidelines are another dogma from the past. I submit our current guidelines are pure FICTION; we use them for convenience and to avoid individualizing NPO guidelines for each patient subtype. Hence, 8 hours was used so nobody has to think about the rules for anesthesia.

Many practices now use 6 hours as a guideline. Is this too over-kill?
Should we be more "liberal" in allowing healthy ASA 1 and 2 patients to eat, drink and be merry with only a 4 hour fasting interval? Should fluids be permitted?

For decades NPO guidelines were like Religion. You didn't ask why you just accepted it as fact.

Another Dogma bites the dust?

Blade

 

[BLADEMDA]

Here is a recent blurb from the ASA Newsletter:
In an attempt to eliminate the possibility of aspiration of gastric contents during anesthesia, ASA published guidelines in 1999 that recommended
a preoperative fasting time of 6 hours following a light meal prior to elective surgery. However, a study from Scotland of health gynecological
patients showed that feeding a light breakfast of buttered toast, and tea or coffee with milk hours preinduction made no difference whatsoever to residual gastric volume or gastric ph compared to a group who were kept "nil by mouth" overnight. A more recent abstract looked at 1,130 patients who ate breakfast up to 2 hours,or drank fluids less than 2 hours preoperatively and found the incidence of regurgitation at induction and emergence had no relation to duration of fasting. In fact, preoperative fasting and dehydration may adversely affect perioperstive well-being and outcome. The administration of a carbohydrate-rich beverage prior to surgery appears to reduce postoperative nause, vomiting, drowsiness and dizziness.

ASA Newsletter
April 2009

 

[dhb]

I think we use the current time frames for convenience. It might not be ideal to have everyone NPO for long periods of time but sometimes a case gets canceled or the surgeon wants to reshuffle the schedule and if the patient just ate you end up losing a lot of time.

 

[2ndyear]

I agree, a lot of it is Dogma. But I would argue we really do need a standard for this. We all would agree that doing an elective case on someone who just ate a large fatty meal (steak or cheeseburger, etc) is probably not in their best interest. There needs to be a fairly clear guideline so that when the patient shows up non-fasted everyone is on the same page. Now I don't know if it has to be a national standard, but at least institutional. Within a group everyone needs to more or less agree.

 

[BLADEMDA]

I agree, a lot of it is Dogma. But I would argue we really do need a standard for this. We all would agree that doing an elective case on someone who just ate a large fatty meal (steak or cheeseburger, etc) is probably not in their best interest. There needs to be a fairly clear guideline so that when the patient shows up non-fasted everyone is on the same page. Now I don't know if it has to be a national standard, but at least institutional. Within a group everyone needs to more or less agree.

Yes. We chose 6 hours for a meal. Any meal. But, as an attending you have the ability to "bend the rules" when you see fit. If the patient is healthy ( no diabetes,moribid obesity) and hasn't eaten in 4 hours then maybe if it is an "urgent" case (like the surgeon has a golf game, dinner, etc.) then consider that the new data strongly hints that it is safe to proceed.

 

[RussianJoo]

http://forums.studentdoctor.net/showthread.php?t=616058&highlight=Dogma

 

[BLADEMDA]

http://forums.studentdoctor.net/showthread.php?t=616058&highlight=Dogma

Thanks for the post. I won't repeat any of that information. Still, NPO Guidelines are huge in this field. A constant daily question from Nurses, Surgeons, etc. no matter what the "stated" policy is at your institution.

 

[BLADEMDA]

So, if a healthy, young female shows up for breast aug at your institution but ate at 0300 (late night snack) would you proceed with the case at 0730?

 

[BLADEMDA]

So, if a healthy, young female shows up for breast aug at your institution but ate at 0300 (late night snack) would you proceed with the case at 0730?

Here is my answer. If I practiced alone, outside a Group, I could do what I want when I wanted. But, in a Group you need standards to avoid CHAOS in the operating room. If I start doing cases with only 4.5 hours of NPO status ELECTIVELY then what about my partners? What about next time when it is an ASA-3 Diabetic, Morbidly obese for a Lap. Chole?

So, while I would do the case on this forum I am not so sure I would REALLY do the case at my institution.

Blade

 

[periopdoc]

Here is my answer. If I practiced alone, outside a Group, I could do what I want when I wanted. But, in a Group you need standards to avoid CHAOS in the operating room. If I start doing cases with only 4.5 hours of NPO status ELECTIVELY then what about my partners? What about next time when it is an ASA-3 Diabetic, Morbidly obese for a Lap. Chole?

So, while I would do the case on this forum I am not so sure I would REALLY do the case at my institution.

Blade

You beat me to my exact answer. Yes it is OK to do the case. No I wouldn't do the case because that is not the standard at my current institution. The partners need to have an agreement about standards like that before going into the OR to avoid confusion and confrontation and to ensure that no individual partner is unduly pressured by the surgeons to bend the rules.

- pod

 

[RussianJoo]

Thanks for the post. I won't repeat any of that information. Still, NPO Guidelines are huge in this field. A constant daily question from Nurses, Surgeons, etc. no matter what the "stated" policy is at your institution.

I think you're making very valid points, and possibly in the future these policies will change, especially as surgeries continue to get less invasive. just wanted to point your attention that thread in case you missed it. that's all.

 

[Impromptu]

NPO makes IVs harder to insert, too. What's wrong with wanting nice, big, juicy veins?