NPO or not NPO, that is the question

[Ketamininus]

Hey all,

Long time since I posted here. I think the last time I posted stuff on SDN, I was still in residency. I am now a recently newly-minted attending (with that new car smell) who is dealing with all the fun %$^% I didn't have to deal with as often as when I was a resident. Try this little gem on for size...

I am running the board in my community hospital, and it is late-afternoon on a Friday. The last case of the day is an add-on I&D of a right thigh hematoma. The patient is coagulopathic (INR 3.1), bad COPD (O2 dependent), obese, and a poorly controlled diabetic. After discussing the case with the surgeon (in particular the INR result), he tells me he needs MAC for a relatively short case.

When I go to interview the patient, he and his wife tell me that he had some Pepsi about 2 hours prior. When I ask how much, he answers "A little. Not very much."

Not knowing exactly how much liquid and considering Pepsi to be a full liquid, I go to discuss this with the surgeon to let him know he will need to wait until 4 hours have passed or do the case with strictly local anesthesia. This is not a surgeon who likes to wait ANY extra time for anything, so I know how that part of the discussion would go.

In essence, he blows up. At me.

As he thunders down the hall yelling at me, stuff like:

"C'mon man, he had a sip of Pepsi 2 hours ago. All I want is 2 of Versed for this I&D. You gotta be F-ing kidding me." (There's more of that, but the rest of it gets kinda salty.)

Just how much liquid do you need to drink to not be NPO? 1 sip? 2 sips? 10 sips? How much?

Given that I wanted to keep all this professional in tone, I motion for him to discuss this in the anesthesia office behind closed doors, which surprisingly he does. I explain to him that the patient is not NPO, it is an elective procedure, and that if anything bad happens during the case as a result of him having a full stomach, then I would have total culpability for it. Did I forget to mention that the patient's wife was a long-time employee of the hospital?? Yeah, it gets better.

For reasons I still cannot fathom, the surgeon decides he wants to tell me how to practice anesthesia.

Stuff like "You could simply say that you used your professional judgement and that is was your clinical opinion that the amount of liquid he consumed was safe enough for the amount of anesthesia you would give." Again, there's more...surgeons like to hear themselves talk...but I won't give all that to you.

I simply respond that the NPO guidelines are "standard of care" and that I will not give anesthesia to that patient at that time. He then thunders off to paint me as a "bad guy" to the patient about how I am refusing to give anesthesia, this all said to the patient. Please keep in mind, that I spent 5 solid minutes talking to the patient and his wife about NPO guidelines and safety in providing anesthesia, how high-risk he was in general, and why I didn't want him to have anesthesia at that exact time.

Suffice to say, the surgeon did the case under local anesthesia. I do not regret that decision, and would make the same decision again every single time. I don't worry about the fact that this surgeon will be unhappy with me henceforth, but there is that concern I have that the chief of my group will counsel me on how to better appease the surgeon in that situation. Ugh.

Anyone have anything similar happen? Comments about what I did? Feedback in general?

Thanks!

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[IN2B8R]

Welcome to PP. Do what's in the best interest of your patient, but don't be a tight arse. Allow room for flexibility (much more than what you were acustomed to in academia). If there is no room, then do what is in the best interest of your patient and what you were taught. When the **** hits the fan and you save one of that surgeon's patients, he'll shut the f*ck up and will start treating you like the rest of the guys in your dept. If he continues to be a d*ck towards you, then, very likely, he's a d*ck towards everyone whom he works with.

Hey all,

Long time since I posted here. I think the last time I posted stuff on SDN, I was still in residency. I am now a recently newly-minted attending (with that new car smell) who is dealing with all the fun %$^% I didn't have to deal with as often as when I was a resident. Try this little gem on for size...

I am running the board in my community hospital, and it is late-afternoon on a Friday. The last case of the day is an add-on I&D of a right thigh hematoma. The patient is coagulopathic (INR 3.1), bad COPD (O2 dependent), obese, and a poorly controlled diabetic. After discussing the case with the surgeon (in particular the INR result), he tells me he needs MAC for a relatively short case.

When I go to interview the patient, he and his wife tell me that he had some Pepsi about 2 hours prior. When I ask how much, he answers "A little. Not very much."

Not knowing exactly how much liquid and considering Pepsi to be a full liquid, I go to discuss this with the surgeon to let him know he will need to wait until 4 hours have passed or do the case with strictly local anesthesia. This is not a surgeon who likes to wait ANY extra time for anything, so I know how that part of the discussion would go.

In essence, he blows up. At me.

As he thunders down the hall yelling at me, stuff like:

"C'mon man, he had a sip of Pepsi 2 hours ago. All I want is 2 of Versed for this I&D. You gotta be F-ing kidding me." (There's more of that, but the rest of it gets kinda salty.)

Just how much liquid do you need to drink to not be NPO? 1 sip? 2 sips? 10 sips? How much?

Given that I wanted to keep all this professional in tone, I motion for him to discuss this in the anesthesia office behind closed doors, which surprisingly he does. I explain to him that the patient is not NPO, it is an elective procedure, and that if anything bad happens during the case as a result of him having a full stomach, then I would have total culpability for it. Did I forget to mention that the patient's wife was a long-time employee of the hospital?? Yeah, it gets better.

For reasons I still cannot fathom, the surgeon decides he wants to tell me how to practice anesthesia.

Stuff like "You could simply say that you used your professional judgement and that is was your clinical opinion that the amount of liquid he consumed was safe enough for the amount of anesthesia you would give." Again, there's more...surgeons like to hear themselves talk...but I won't give all that to you.

I simply respond that the NPO guidelines are "standard of care" and that I will not give anesthesia to that patient at that time. He then thunders off to paint me as a "bad guy" to the patient about how I am refusing to give anesthesia, this all said to the patient. Please keep in mind, that I spent 5 solid minutes talking to the patient and his wife about NPO guidelines and safety in providing anesthesia, how high-risk he was in general, and why I didn't want him to have anesthesia at that exact time.

Suffice to say, the surgeon did the case under local anesthesia. I do not regret that decision, and would make the same decision again every single time. I don't worry about the fact that this surgeon will be unhappy with me henceforth, but there is that concern I have that the chief of my group will counsel me on how to better appease the surgeon in that situation. Ugh.

Anyone have anything similar happen? Comments about what I did? Feedback in general?

Thanks!

 

[Surfer]

I would have given 2 of versed (maybe a light propofol dose too). Pepsi is a clear liquid, and he'll be awake to protect his airway. I'll also give some zofran and reglan. Get the case done and go HIT THOSE HUGE WAVES!!

 

[Fastrach]

I would have given 2 of versed (maybe a light propofol dose too). Pepsi is a clear liquid, and he'll be awake to protect his airway. I'll also give some zofran and reglan. Get the case done and go HIT THOSE HUGE WAVES!!

Since when?

 

[Surfer]

Since when?

Since 1992.

Actually, normal pepsi is a clear liquid too. Food coloring doesn't make it a "full liquid"

 

[sevoflurane]

Hey all,

Long time since I posted here. I think the last time I posted stuff on SDN, I was still in residency. I am now a recently newly-minted attending (with that new car smell) who is dealing with all the fun %$^% I didn't have to deal with as often as when I was a resident. Try this little gem on for size...

I am running the board in my community hospital, and it is late-afternoon on a Friday. The last case of the day is an add-on I&D of a right thigh hematoma. The patient is coagulopathic (INR 3.1), bad COPD (O2 dependent), obese, and a poorly controlled diabetic. After discussing the case with the surgeon (in particular the INR result), he tells me he needs MAC for a relatively short case.

When I go to interview the patient, he and his wife tell me that he had some Pepsi about 2 hours prior. When I ask how much, he answers "A little. Not very much."

Not knowing exactly how much liquid and considering Pepsi to be a full liquid, I go to discuss this with the surgeon to let him know he will need to wait until 4 hours have passed or do the case with strictly local anesthesia. This is not a surgeon who likes to wait ANY extra time for anything, so I know how that part of the discussion would go.

In essence, he blows up. At me.

As he thunders down the hall yelling at me, stuff like:

"C'mon man, he had a sip of Pepsi 2 hours ago. All I want is 2 of Versed for this I&D. You gotta be F-ing kidding me." (There's more of that, but the rest of it gets kinda salty.)

Just how much liquid do you need to drink to not be NPO? 1 sip? 2 sips? 10 sips? How much?

Given that I wanted to keep all this professional in tone, I motion for him to discuss this in the anesthesia office behind closed doors, which surprisingly he does. I explain to him that the patient is not NPO, it is an elective procedure, and that if anything bad happens during the case as a result of him having a full stomach, then I would have total culpability for it. Did I forget to mention that the patient's wife was a long-time employee of the hospital?? Yeah, it gets better.

For reasons I still cannot fathom, the surgeon decides he wants to tell me how to practice anesthesia.

Stuff like "You could simply say that you used your professional judgement and that is was your clinical opinion that the amount of liquid he consumed was safe enough for the amount of anesthesia you would give." Again, there's more...surgeons like to hear themselves talk...but I won't give all that to you.

I simply respond that the NPO guidelines are "standard of care" and that I will not give anesthesia to that patient at that time. He then thunders off to paint me as a "bad guy" to the patient about how I am refusing to give anesthesia, this all said to the patient. Please keep in mind, that I spent 5 solid minutes talking to the patient and his wife about NPO guidelines and safety in providing anesthesia, how high-risk he was in general, and why I didn't want him to have anesthesia at that exact time.

Suffice to say, the surgeon did the case under local anesthesia. I do not regret that decision, and would make the same decision again every single time. I don't worry about the fact that this surgeon will be unhappy with me henceforth, but there is that concern I have that the chief of my group will counsel me on how to better appease the surgeon in that situation. Ugh.

Anyone have anything similar happen? Comments about what I did? Feedback in general?

Thanks!

Sorry to hear that man. How annoying and disrespectful. I ran into this my first month in PP, so I feel for you. He was probably trying to see what he could get away with in regards to the new guy on the block. I told him to write it in the chart that it was deemed a surgical emergency. If not, then I wasn't doing it. I then wrote a nice little paragraph regarding our conversation. Fortunately my case didn't have an INR of 3 so I did good old fashioned regional. He was very thankful afterwards and has not asked anything like that since. We try to keep a good relationship between surgery and anesthesia... Once you become friends, you will see a lot of give and take from both sides of the fence. As mentioned above, patients come first.

 

[militarymd]

uhhh...pepsi is a clear liquid....and with clear liquids...you can have a gallon...and 2 hours is MORE than enough.


Your surgeon was right....you were wrong.

AND...these are "recommendations" NOT "standard of care"

 

[Ketamininus]

Right or wrong, I had been instructed that any liquid I couldn't see through was a full liquid. Black coffee...OK. Coffee with cream, not OK.

Yes, I know they're guidelines. However, EVERY anesthesiologist I ever worked with did not vary from the guidelines when it came to NPO status. Too much risk.

Bottom line as I see it. It's my medical license and liability on the line for these decisions, not to mention the overriding notion to do the safest thing for the patient. I have done my best to accommodate surgeons in the past, but this guy was a pr@ck of the highest order about the whole thing. Part of the thing about being new in PP is that I find myself to be highly conservative in the management of my patients.

C'est la vie...live and learn.

 

[militarymd]

Right or wrong, I had been instructed that any liquid I couldn't see through was a full liquid. Black coffee...OK. Coffee with cream, not OK.

Yes, I know they're guidelines. However, EVERY anesthesiologist I ever worked with did not vary from the guidelines when it came to NPO status. Too much risk.

Bottom line as I see it. It's my medical license and liability on the line for these decisions, not to mention the overriding notion to do the safest thing for the patient. I have done my best to accommodate surgeons in the past, but this guy was a pr@ck of the highest order about the whole thing. Part of the thing about being new in PP is that I find myself to be highly conservative in the management of my patients.

C'est la vie...live and learn.

He was a prick because you were wrong and being obstinate about it.

YOU were the one who brought up the guidelines......so if you had read the guidelines, then you would know that pepsi is considered a "clear"...and 2 hours is enough time.

 

[MDEntropy]

Ketamininus,

There is nothing technically wrong with your decision although, I think you might reconsider the reasoning behind your decision.

Even if you classify pepsi as a clear liquid, which I think you should, 2 hours is the minimum waiting time recommended.

What is not shown in the pasted portion of the fasting guidelines, but is included, is that patients who are obese, or diabetics with delayed gastric emptying, etc. should be given be longer NPO periods prior to an elective procedure.

While I am not familiar with full liquids separate from a regular meal in the setting of the ASA fasting guidelines, and 4 hours seems arbitrary, your decision is not unreasonable. If you read the guidelines, and refer directly to them in your discussions, you will know when you are being arbitrary and recognize that the only rules are the absolute minimums.

Just yesterday I brought up this issue in another thread. I thought it might bring about more discussion, even though I tend to agree with what most people said in response. In the end, it seems we all tend to lean toward the absolute minimum. In your case, you didn't go with the minimum, and it is reasonable not to. Perhaps trying to align your reasoning with that in the fasting guidelines will allow you to be more confident about your decisions in this area even when being arbitrary. This will come up over and over and over again.

 

[KungPOWChicken]

Actually MilMD. those guidelines refer to healthy patients, which obviously this guy was not. I've seen enough patients who are tubed and post ogt we suck out a big mac. Meaning patients are unreliable. If you're concerned about it, delay the case. If you're not, go ahead. Use your own judgement, but It's not wrong delaying in an unhealthy unreliable patient.

 

[militarymd]

Actually MilMD. those guidelines refer to healthy patients, which obviously this guy was not. I've seen enough patients who are tubed and post ogt we suck out a big mac. Meaning patients are unreliable. If you're concerned about it, delay the case. If you're not, go ahead. Use your own judgement, but It's not wrong delaying in an unhealthy unreliable patient.

so what's your point? In my practice, we don't take care of any patients that fall into the patient population as defined by the guidelines...and yet we all follow them.

It's NEVER wrong "medical-legally".......but it won't get you any "political capital".

 

[Mac4]

While I agree guidlines are RECOMMENDATIONS, I do not think OP was wrong delaying the case. This guy is poorly controlled diabetic, O2 dependent, obese, etc..he is a set-up for apnea and aspiration if you give him 2 versed.

 

[Narcotized]

.

 

[Narcotized]

uhhh...pepsi is a clear liquid....and with clear liquids...you can have a gallon...and 2 hours is MORE than enough.

Mil, I came to same conclusion as you, but my question is always the volume. I'm unaware of any recommendations. I'm not putting someone to sleep 2 hours after a gallon of liquid. I don't believe someone isn't still distended and at increased risk after just 2 hours. Is there anything more specific written down somewhere?

 

[militarymd]

Mil, I came to same conclusion as you, but my question is always the volume. I'm unaware of any recommendations. I'm not putting someone to sleep 2 hours after a gallon of liquid. I don't believe someone isn't still distended and at increased risk after just 2 hours. Is there anything more specific written down somewhere?

there is....but I can't remember where I read it....and it confirmed my own experience deal with patients.

 

[monchi]

Mil, I came to same conclusion as you, but my question is always the volume. I'm unaware of any recommendations. I'm not putting someone to sleep 2 hours after a gallon of liquid. I don't believe someone isn't still distended and at increased risk after just 2 hours. Is there anything more specific written down somewhere?

I was thinking that too... that there is a volume.
One of my attendings told me the magic number was 0.4ml/kg.

I did a quick search on that, and just found this so far:
http://www.asahq.org/rcls/RCLS_SRC/274_Stoelting.pdf
and there are some references listed.

 

[IlDestriero]

.

 

[2win]

Hey all,

Long time since I posted here. I think the last time I posted stuff on SDN, I was still in residency. I am now a recently newly-minted attending (with that new car smell) who is dealing with all the fun %$^% I didn't have to deal with as often as when I was a resident. Try this little gem on for size...

I am running the board in my community hospital, and it is late-afternoon on a Friday. The last case of the day is an add-on I&D of a right thigh hematoma. The patient is coagulopathic (INR 3.1), bad COPD (O2 dependent), obese, and a poorly controlled diabetic. After discussing the case with the surgeon (in particular the INR result), he tells me he needs MAC for a relatively short case.

When I go to interview the patient, he and his wife tell me that he had some Pepsi about 2 hours prior. When I ask how much, he answers "A little. Not very much."

Not knowing exactly how much liquid and considering Pepsi to be a full liquid, I go to discuss this with the surgeon to let him know he will need to wait until 4 hours have passed or do the case with strictly local anesthesia. This is not a surgeon who likes to wait ANY extra time for anything, so I know how that part of the discussion would go.

In essence, he blows up. At me.

As he thunders down the hall yelling at me, stuff like:

"C'mon man, he had a sip of Pepsi 2 hours ago. All I want is 2 of Versed for this I&D. You gotta be F-ing kidding me." (There's more of that, but the rest of it gets kinda salty.)

Just how much liquid do you need to drink to not be NPO? 1 sip? 2 sips? 10 sips? How much?

Given that I wanted to keep all this professional in tone, I motion for him to discuss this in the anesthesia office behind closed doors, which surprisingly he does. I explain to him that the patient is not NPO, it is an elective procedure, and that if anything bad happens during the case as a result of him having a full stomach, then I would have total culpability for it. Did I forget to mention that the patient's wife was a long-time employee of the hospital?? Yeah, it gets better.

For reasons I still cannot fathom, the surgeon decides he wants to tell me how to practice anesthesia.

Stuff like "You could simply say that you used your professional judgement and that is was your clinical opinion that the amount of liquid he consumed was safe enough for the amount of anesthesia you would give." Again, there's more...surgeons like to hear themselves talk...but I won't give all that to you.

I simply respond that the NPO guidelines are "standard of care" and that I will not give anesthesia to that patient at that time. He then thunders off to paint me as a "bad guy" to the patient about how I am refusing to give anesthesia, this all said to the patient. Please keep in mind, that I spent 5 solid minutes talking to the patient and his wife about NPO guidelines and safety in providing anesthesia, how high-risk he was in general, and why I didn't want him to have anesthesia at that exact time.

Suffice to say, the surgeon did the case under local anesthesia. I do not regret that decision, and would make the same decision again every single time. I don't worry about the fact that this surgeon will be unhappy with me henceforth, but there is that concern I have that the chief of my group will counsel me on how to better appease the surgeon in that situation. Ugh.

Anyone have anything similar happen? Comments about what I did? Feedback in general?

Thanks!

Happened I think to most of us.
If you as a "specialist" believe that is not safe to do anesthesia for a patient (doesn't matter which type) - you don't do it and that's it.
In this specific case - beside that the surgeon is suggesting the type of anesthesia (****** IMO) - if he's writing in the chart "emergency surgery" basically you don't care anymore (document your concerns too).
The relation with that specific surgeon in the future could be a tensioned one ...Politically ( after some years in PP...) I would do the case without any problem - and get out ASAP from OR to enjoy my life.
Discussing in front of the patient your decision and "suggesting" that you refuse anesthesia is totally unprofessional and has to be brought in the attention of the medical director of the hospital and if you really want you can bring it in front of the board. This is a NO, NO.
However I think you don't gonna stay to long there...
I am right?

 

[nap$ter]

He was a prick because you were wrong and being obstinate about it.

YOU were the one who brought up the guidelines......so if you had read the guidelines, then you would know that pepsi is considered a "clear"...and 2 hours is enough time.

i agree with mil - you were wrong. a prick is still a prick, but this was a battle you shouldn'ta picked.

if you're concerned - 0.5mg versed at a time +/- careful propofol gtt, lotsa local, reverse t, reglan, bicitra, zofran.

lookin forward to private practice...

 

[2win]

i agree with mil - you were wrong. a prick is still a prick, but this was a battle you shouldn'ta picked.

if you're concerned - 0.5mg versed at a time +/- careful propofol gtt, lotsa local, reverse t, reglan, bicitra, zofran.

lookin forward to private practice...

"lookin forward to private practice" - I hear over and over this statement...
Private practice in anaesthesia isn't the paradise. Maybe better money ( and I don't know for how long) but definitely has its own caveats.
My prediction is that the "old style" of private practice will disappear soon.
Hospital employee is the future. And is valid for all medical specialities except maybe cosmetic surgery. There you'll not get an incentive to do cases *neither the surgeon...This type of discussion will become obsolete - actually to postpone cases will be the usual approach - see Canada and EU...
Time will tell...

 

[dhb]

actually to postpone cases will be the usual approach - see Canada and EU...
Time will tell...

Please...

 

[Narcotized]

I was thinking that too... that there is a volume.
One of my attendings told me the magic number was 0.4ml/kg.

That's only about one ounce in a 70 kg patient. That's sound more like what maybe he'd allow immediately prior to intubation. I'm comfortable with more than one ounce of clear liquids 2 hours prior and not so comfortable with a gallon.

I'm curious, as more and more people feel comfortable with the updated guidelines, why don't we tell patients you can have a cup or so of water when you get up in the am atleast 2 hrs prior to surgery? As far as I'm aware, everyone still gets the "nothing after midnight except meds with a small sip."

 

[Licoricestick]

I'm curious, as more and more people feel comfortable with the updated guidelines, why don't we tell patients you can have a cup or so of water when you get up in the am atleast 2 hrs prior to surgery? As far as I'm aware, everyone still gets the "nothing after midnight except meds with a small sip."

That's exactly what we're doing for our day of surgery admissions/day surg patients - if the list is an AM start (either all day or half day list) it's nothing after midnight, except they can have one small glass of water (~150mL) per hour until 2hrs before they are supposed to present to the admissions suite (so that way if we reorder the list they are still fasted on arrival).

If the list is a PM start then they can have a light breakfast, fast after that, and the same rules about water.

What bugs me most is fighting the wards about inpatients on elective lists (especially where they are first up). The nurses have this attitude that all fasting patients must have IVT, so they call the intern, who puts a drip in and writes up IVT (cause the interns know jack about anaesthetics and even if they are sensible, fighting with the nurses about this twice a shift isn't worth it). So the patient gets woken up at midnight to have their IVT started, and then they come to theatre with a 20 or 22G IV in their cubital fossa....sucks for us if we wanted to use it for a 14G.

No matter how many times I and my colleagues explain to nursing staff "This patient is the first patient on the elective list, if he were at home he would be fasting from midnight without any IVT until he enters the operating room. He does not need IV access and IVT on the ward. And he certainly doesn't need IVT from midnight as is written on the chart - do you drink at 1am in the morning?" Nothing changes. Ditto for explaining that patients coming for surgery should have their usual meds...especially the ones for reflux and cardiac issues. Or the patient is fasting so for some reason isn't entitled to analgesia. 😱

 

[GoodmanBrown]

i agree with mil - you were wrong. a prick is still a prick, but this was a battle you shouldn'ta picked.

if you're concerned - 0.5mg versed at a time +/- careful propofol gtt, lotsa local, reverse t, reglan, bicitra, zofran.

lookin forward to private practice...

This is exactly what I was thinking. Won't 1 of versed with some extra local placate the surgeon while reducing the risk of a compromised airway?

 

[jwk]

I had been instructed that any liquid I couldn't see through was a full liquid. Black coffee...OK. Coffee with cream, not OK.

.

From a "clear" standpoint, what's the difference between black coffee and Pepsi? 😕

 

[dhb]

From a "clear" standpoint, what's the difference between black coffee and Pepsi? 😕

yoiu could even argue that coffee is a particulate matter...

 

[jwk]

yoiu could even argue that coffee is a particulate matter...

They have that new "coffee filter" concept that takes care of that. 😉

 

[IlDestriero]

They have that new "coffee filter" concept that takes care of that. 😉

Drip coffee = clear.
Turkish coffee = solid. 😉

 

[urge]

Hey all,

Long time since I posted here. I think the last time I posted stuff on SDN, I was still in residency. I am now a recently newly-minted attending (with that new car smell) who is dealing with all the fun %$^% I didn't have to deal with as often as when I was a resident. Try this little gem on for size...

I am running the board in my community hospital, and it is late-afternoon on a Friday. The last case of the day is an add-on I&D of a right thigh hematoma. The patient is coagulopathic (INR 3.1), bad COPD (O2 dependent), obese, and a poorly controlled diabetic. After discussing the case with the surgeon (in particular the INR result), he tells me he needs MAC for a relatively short case.

When I go to interview the patient, he and his wife tell me that he had some Pepsi about 2 hours prior. When I ask how much, he answers "A little. Not very much."

Not knowing exactly how much liquid and considering Pepsi to be a full liquid, I go to discuss this with the surgeon to let him know he will need to wait until 4 hours have passed or do the case with strictly local anesthesia. This is not a surgeon who likes to wait ANY extra time for anything, so I know how that part of the discussion would go.

In essence, he blows up. At me.

As he thunders down the hall yelling at me, stuff like:

"C'mon man, he had a sip of Pepsi 2 hours ago. All I want is 2 of Versed for this I&D. You gotta be F-ing kidding me." (There's more of that, but the rest of it gets kinda salty.)

Just how much liquid do you need to drink to not be NPO? 1 sip? 2 sips? 10 sips? How much?

Given that I wanted to keep all this professional in tone, I motion for him to discuss this in the anesthesia office behind closed doors, which surprisingly he does. I explain to him that the patient is not NPO, it is an elective procedure, and that if anything bad happens during the case as a result of him having a full stomach, then I would have total culpability for it. Did I forget to mention that the patient's wife was a long-time employee of the hospital?? Yeah, it gets better.

For reasons I still cannot fathom, the surgeon decides he wants to tell me how to practice anesthesia.

Stuff like "You could simply say that you used your professional judgement and that is was your clinical opinion that the amount of liquid he consumed was safe enough for the amount of anesthesia you would give." Again, there's more...surgeons like to hear themselves talk...but I won't give all that to you.

I simply respond that the NPO guidelines are "standard of care" and that I will not give anesthesia to that patient at that time. He then thunders off to paint me as a "bad guy" to the patient about how I am refusing to give anesthesia, this all said to the patient. Please keep in mind, that I spent 5 solid minutes talking to the patient and his wife about NPO guidelines and safety in providing anesthesia, how high-risk he was in general, and why I didn't want him to have anesthesia at that exact time.

Suffice to say, the surgeon did the case under local anesthesia. I do not regret that decision, and would make the same decision again every single time. I don't worry about the fact that this surgeon will be unhappy with me henceforth, but there is that concern I have that the chief of my group will counsel me on how to better appease the surgeon in that situation. Ugh.

Anyone have anything similar happen? Comments about what I did? Feedback in general?

Thanks!

Know how I know you didn't read much as a resident?

 

[Arch Guillotti]

Know how I know you didn't read much as a resident?

Does it really matter? The learning curve as a new attending is very steep. Not only do you have to make judgment calls based on limited info, you also have to deal with all sorts of different personalities in a different manner than you are accustomed to as a resident. All this while trying to do a dozen other different things at one time. The OP shared an experience that sparked some interesting discussion, let's keep it that way.

 

[siednarb]

Funny - I had a problem with an OB attending and the NPO guidelines on Friday.

35 yr old female, 27 weeks, needs C-section due to reversed doppler's and IUGR, had a bowl of cereal at 8 am and a bagel with cream cheese at 9 am. OB tells me that they are going to do section at 3 pm - matter-of-factly.

I tell them "This patient had a bagel w/cc at 3, so you can do the C-section at 5 p.m. unless of course the OB would like to document that this is an urgent/emergent C-section we can do the section now" (they notified me about this at 10 am)

So the OB attending gets in my face and quickly asserts to me that it has always been 6 hours after food at this hospital and all my partners would do it after 6 hours. I tell her the NPO guidelines state 6 hours for a light meal and that this I would not consider her breakfast this morning a light meal. She get's pissed, pages my chairman (who backs me up).

I polled some of my partners - some said they would have done the section after 6 hours because all parturients have a full stomach no matter if you had waited 8 hours or 10 hours and others said I did the right thing.

Thoughts?

 

[nap$ter]

Funny - I had a problem with an OB attending and the NPO guidelines on Friday.

35 yr old female, 27 weeks, needs C-section due to reversed doppler's and IUGR, had a bowl of cereal at 8 am and a bagel with cream cheese at 9 am. OB tells me that they are going to do section at 3 pm - matter-of-factly.

I tell them "This patient had a bagel w/cc at 3, so you can do the C-section at 5 p.m. unless of course the OB would like to document that this is an urgent/emergent C-section we can do the section now" (they notified me about this at 10 am)

So the OB attending gets in my face and quickly asserts to me that it has always been 6 hours after food at this hospital and all my partners would do it after 6 hours. I tell her the NPO guidelines state 6 hours for a light meal and that this I would not consider her breakfast this morning a light meal. She get's pissed, pages my chairman (who backs me up).

I polled some of my partners - some said they would have done the section after 6 hours because all parturients have a full stomach no matter if you had waited 8 hours or 10 hours and others said I did the right thing.

Thoughts?

why did you decide on 8 hrs as the necessary time?

 

[sevoflurane]

Up to you and what you think is safe. Nothing wrong with what you did and your OB guy needs to respect your decision. Personally, I'd give some reglan and done the case. As Mil mentioned, they are guidelines not absolutes.

 

[2win]

👍

Up to you and what you think is safe. Nothing wrong with what you did and your OB guy needs to respect your decision. Personally, I'd give some reglan and done the case. As Mil mentioned, they are guidelines not absolutes.

What is wrong with anesthesiologists?
You don't have to tun to your partners or to pull up evidence to justify a decision....
Just think, take a decision and that's it.
And I wonder why we are in this position - a lot of pu:":"ssies in this field....

 

[sevoflurane]

why did you decide on 8 hrs as the necessary time?

Some would adhere to "fatty/fried foods" as a heavy meal and wait 8 hrs. Not sure how fatty cream cheese really is. Guidelines are recommendations. If you want to be on the same page with your fellow surgeons you need to give a little, as long as you feel the patient is being taken care of.

 

[bullard]

Pregnant women are full stomachs no matter what and all too often they lie. Bicitra, Zantac, Reglan. Wait 6 hours if you want to...I would tell the OB to document it as urgent and then just do it when convenient, i.e. after lunch. 🙂 I really haven't had problems with OBs not wanting to document urgency.

I think you have to pick your battles so that when you do need to delay/cancel a case, the surgeon/OB ears perk up because they know you're not an obstructionist. Waiting two hours may or may not put you a little more in line with the NPO guidelines (I don't think it does in this case, but whatever), but it really doesn't make the anesthetic appreciably safer. Put a different way, a competent anesthesiologist should be able to prevent aspiration in this patient regardless of when you decide to proceed with the case.

IMHO.

Funny - I had a problem with an OB attending and the NPO guidelines on Friday.

35 yr old female, 27 weeks, needs C-section due to reversed doppler's and IUGR, had a bowl of cereal at 8 am and a bagel with cream cheese at 9 am. OB tells me that they are going to do section at 3 pm - matter-of-factly.

I tell them "This patient had a bagel w/cc at 3, so you can do the C-section at 5 p.m. unless of course the OB would like to document that this is an urgent/emergent C-section we can do the section now" (they notified me about this at 10 am)

So the OB attending gets in my face and quickly asserts to me that it has always been 6 hours after food at this hospital and all my partners would do it after 6 hours. I tell her the NPO guidelines state 6 hours for a light meal and that this I would not consider her breakfast this morning a light meal. She get's pissed, pages my chairman (who backs me up).

I polled some of my partners - some said they would have done the section after 6 hours because all parturients have a full stomach no matter if you had waited 8 hours or 10 hours and others said I did the right thing.

Thoughts?

 

[IlDestriero]

.

 

[IlDestriero]

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[Ketamininus]

I appreciate all the feedback on this thread. It seems obvious that I erred, and I all I can do is learn from it, move on, and not let the same mistake happen again.

To those who took pot-shots at either my reading habits or my residency training, all I can say to you is that you probably felt pretty pretty satisfied with yourself when you left that comment. Kinda sad, really.

For those who have been in any way supportive of the situation I was in, I do appreciate it. There's some solace for me in knowing that this was neither my first mistake, nor will it be my last. Can't dwell on that, though

I'm done with this thread. Consider this one now:

"The Mesozoic era was neither Mesozoic nor an era. Discuss."

 

[Planktonmd]

I appreciate all the feedback on this thread. It seems obvious that I erred, ....

Actually I don't think you erred!
You did what many practicing anesthesiologists would have done.
You were conservative and chose the safest approach possible to this situation.
All these NPO guidelines are still immature and open to personal interpretation by the consultant anesthesiologist (You)!
So, you did not make a clinical mistake I assure you, but maybe you did a political misjudgment since at this point in your career you really need to pick your battles carefully.

 

[foxtrot]

I appreciate all the feedback on this thread. It seems obvious that I erred, and I all I can do is learn from it, move on, and not let the same mistake happen again.

To those who took pot-shots at either my reading habits or my residency training, all I can say to you is that you probably felt pretty pretty satisfied with yourself when you left that comment. Kinda sad, really.

For those who have been in any way supportive of the situation I was in, I do appreciate it. There's some solace for me in knowing that this was neither my first mistake, nor will it be my last. Can't dwell on that, though

I'm done with this thread. Consider this one now:

"The Mesozoic era was neither Mesozoic nor an era. Discuss."

I don't think you erred either. It was a good discussion on NPO guidelines and how many times they are just guidelines. Live and learn. There are always going to be those on this forum that take it upon themselves to always make rude comments rather than create an educational discussion because it allows them to feel superior to everyone else (you know who I am talking about). I think you should still keep posting.