"one bite of pudding"

[southeastgas]

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What would YOU do? Honestly....
Private practice gig, patient scheduled for I and D of foot/ankle at 3:30pm. I get a call from orthopedic doc at 1pm saying that the patient was given a pudding cup by the nurse aid and the patient had ONE bite of pudding before the nurse took it away. He wants to know if we can proceed.....
This is a fairly in depth I and D which will take a min of 40 min.

Pt has HTN and arthritis. NPO status prior to pudding was greater than 8 hours...

 

[Gasworks]

whenever a nurse/surgeon/patient tells you about their NPO slipup just add "and a cheeseburger" to whatever they said and decide if you'll do the case. So 1 bite of pudding and a cheeseburger means the patient goes home or the surgeon can come back after his dinner and do the case. The places I work all specifically tell the patients no gum chewing or sucking candy prior to surgery and more than once the nurses have sent a pt home before we even see them because they walked in sucking on a jolly rancher.

If this pt should happen to aspirate on the "1 bite of pudding" the lawyers will take a copy of your hospital's NPO guidelines and skillfully cut your throat with it. Would you walk up to the surgeon and ask him to fix a broken radius with a bag of screws from home depot? Think about his reaction to that and fashion your response accordingly.

 

[IN2B8R]

whenever a nurse/surgeon/patient tells you about their NPO slipup just add "and a cheeseburger" to whatever they said and decide if you'll do the case. So 1 bite of pudding and a cheeseburger means the patient goes home or the surgeon can come back after his dinner and do the case. The places I work all specifically tell the patients no gum chewing or sucking candy prior to surgery and more than once the nurses have sent a pt home before we even see them because they walked in sucking on a jolly rancher.

If this pt should happen to aspirate on the "1 bite of pudding" the lawyers will take a copy of your hospital's NPO guidelines and skillfully cut your throat with it. Would you walk up to the surgeon and ask him to fix a broken radius with a bag of screws from home depot? Think about his reaction to that and fashion your response accordingly.

Love the analogy👍

 

[JSBMD]

Good real-world example for the kids here. This happens with some degree of regularity. Not common, but not unheard of.

We all know the ASA guidelines. We all (I hope) buy into the guidelines. So, should be a no-brainer, right? In residency any p!ssing match will be won by the more senior resident on either side, or by the louder/stronger attending involved. But private world is not quite the same. Recall everyone, in the private world the administrators usually kiss surgeon ***** because it is they who bring the customers (patients) as fertilizer to the cash tree (the OR). We are symbiotic beings who must be part of the tree fertilizing. In other words, we are a necessary evil, and all parties know this.

Heaven forbid this is your first case in private practice, 'cause the surgeon will form a very strong opinion of you based on this case. Whatever you choose to do, he will "brand" you based on that. If that is the case, I would ask one of your new colleagues for assistance in the form of a second opinion given in front of the surgeon. Trust me, if there is any such thing as "surgeon request" at your facility, you do NOT want to be known as "The Case Canceller". If you have a pre-existing (hopefully solid) relationship with the surgeon, your job is much easier here. Either way, as has been pointed out, if the patient aspirates, you are dust. Same surgeon who pushed you to do the case will plead ignorance as to the NPO guidelines, or else defer to your judgement (and say as such in a deposition).

So, all that said, what would I do? I would first remind the surgeon of the NPO guidelines and ASA recommendations, tell them of a colleague's experience with an aspiration, and then bounce it right back to them. Namely, I would say that since I am not a board certified surgeon, I cannot state just how "emergent" this case is or isn't. Thus, if the surgeon wishes to proceed with this case as it is emergent, that I don't care if the patient still has the cheeseburger still in his hands (yes, I actually do say this) we shall proceed with the case. I of course indicate that I need to know if it's an emergency or not because that allows me to justify my actions should anything go poorly.

In 14 years of private practice, I have encountered this scenario maybe 10 times (where the patient with full stomach is not a true emergency), including last week in a surgeon-owned outpatient facility. Never had to do the "full stomach" case except when legitimately an emergency. Seems that everyone knows the real answer in these situations, the surgeons just sometimes try to get away with one.

What did you do?

 

[southeastgas]

Wow, that is basically what I did...
I quickly reminded the surgeon of the guidelines,
Told him how I would be toast in court if he did aspirate,
Then told him I would gladly proceed if he felt it were emergent.
He went on to say how he has been trying to get this case done for the last 4 days and would love ti get it done today, I then said again that if it were declared emergent I would happily oblige. He then said it will just have to go this (saturday) morning even though he had plans....
The reason I bring this situation up is that I know alot of my senior partners would have done the case no questions asked... Which is why the surgeon asked me if we could proceed, sometimes anesthesia says yes.
It all worked out in the end as the surgeon didn't want to declare emergent. I was just wondering how many people out there find themselves bending the rules in situations like.... For fear of being the "case canceler"

 

[pgg]

Namely, I would say that since I am not a board certified surgeon, I cannot state just how "emergent" this case is or isn't.

👍 I think this is almost always the best answer.

"He's not NPO and is at risk for aspiration. If you feel the case needs to go now, we'll document it as an emergency, and we can be in the OR in 5 minutes."

Let the surgeons play loose games with their definitions and guidelines, if they're in such a hurry.

 

[IlDestriero]

I usually get this through a resident or fellow. For the obviously urgent but not emergent cases, or ones that are bogus or unclear, I remind them of the guidelines, which are hospital policy, and tell them that if the attending surgeon declares the case a true emergency that cannot wait (in front of the OR nurse) we can go immediately. They never seem to want to want to do that. Ortho is the biggest offender with this issue, it's amazing how many emergency fractures that can't go by 7 are fine to wait until morning. I'm pretty liberal with "required" labs, blood products, studies, lines, etc. Several of my partners are comically conservative. One thing I generally don't screw around with is NPO rules. I will call lots of things a "light meal" and do them at 6 hours though. One spoon (full cup) of pudding sounds like a 6hr meal to me.
One attending left the group recently to go to private practice. This person would cancel anything and everything for any available excuse. I wonder how that will turn out? Probably do the cases and make the dollars. Getting paid to work, or not, change the equation dramatically.

 

[pgg]

I will call lots of things a "light meal" and do them at 6 hours though. One spoon (full cup) of pudding sounds like a 6hr meal to me.

CRNA and gen surgeon were arguing whether or not watermelon was a clear liquid last week. I think they ended up doing the case (a colonoscopy) after 4 hours.


What kind of person chases their bowel prep with a watermelon on the way to the hospital?

 

[jwk]

👍 I think this is almost always the best answer.

"He's not NPO and is at risk for aspiration. If you feel the case needs to go now, we'll document it as an emergency, and we can be in the OR in 5 minutes."

Let the surgeons play loose games with their definitions and guidelines, if they're in such a hurry.

The only difference we would do is we would have the SURGEON document in the record that it's an emergency. We call that bluff all the time for all sorts of stuff - bad NPO status, K+ 2.2, Na+ 110, etc.

 

[cchoukal]

CRNA and gen surgeon were arguing whether or not watermelon was a clear liquid last week. I think they ended up doing the case (a colonoscopy) after 4 hours.


What kind of person chases their bowel prep with a watermelon on the way to the hospital?

Fair question. But I could almost side with watermelon being a clear. Isn't it like 95% water?

 

[Gimlet]

It sounds like it rarely happens, but what kind of documentation would you require if the surgeon did decide to change the case status to emergent? Write it in a progress note? Change the posting slip? I don't know if I would trust them to dictate that the "patient was brought emergently to the OR" in their op report.

 

[Idiopathic]

It sounds like it rarely happens, but what kind of documentation would you require if the surgeon did decide to change the case status to emergent? Write it in a progress note? Change the posting slip? I don't know if I would trust them to dictate that the "patient was brought emergently to the OR" in their op report.

there is certainly room for that in your chart, be it paper or electronic. obviously dont want to get in a he said she said over it, but still.

 

[IlDestriero]

It sounds like it rarely happens, but what kind of documentation would you require if the surgeon did decide to change the case status to emergent? Write it in a progress note? Change the posting slip? I don't know if I would trust them to dictate that the "patient was brought emergently to the OR" in their op report.

If it was questionable, I would document it in the anesthesia record "Discussed NPO status with Dr. Attending Surgeon who declared the case an emergency and that it could not wait x hours." I would also instruct the nurse to document the same thing in the nursing note. If it's a run of the mill real emergency, we have a line in the electronic record to note it is an emergency (yes/no).
If it really was total BS, I would have a "discussion" with the attending Surgeon face to face before going to sleep and require he/she sign a note in the chart calling it an emergency. If they document that it's an emergency, who am I to say it's not. This has not happened, but a situation where it was clearly not an emergency, but documented as such, would generate an event report and risk management's involvement. I'm not going down for a cowboy dbag and the hospital doesn't want that liability either. I would also email the chief of surgery my concerns. You have to be professional, that behavior crosses the line.

 

[epidural man]

What would YOU do? Honestly....
Private practice gig, patient scheduled for I and D of foot/ankle at 3:30pm. I get a call from orthopedic doc at 1pm saying that the patient was given a pudding cup by the nurse aid and the patient had ONE bite of pudding before the nurse took it away. He wants to know if we can proceed.....
This is a fairly in depth I and D which will take a min of 40 min.

Pt has HTN and arthritis. NPO status prior to pudding was greater than 8 hours...

I think the problem is that there is very little data about NPO status - it's essentially all made up crap anyway.

If I am healthy (no pain, no sickeness, etc.), there is no way food stays in my belly for 8 hours - probably doesn't stay for 2 hours.

In a fatty, I bet that food is gone in 20 minutes.

Wasn't there recent discussion/editorial/study in Anesthesiology about how bogus our NPO guidelines are?

 

[jwk]

It sounds like it rarely happens, but what kind of documentation would you require if the surgeon did decide to change the case status to emergent? Write it in a progress note? Change the posting slip? I don't know if I would trust them to dictate that the "patient was brought emergently to the OR" in their op report.

We don't quibble about little things in our group. We rarely cancel or delay cases.

A case from yesterday - "GI Bleed" in a patient with a Hgb of 14 with a bonafide MI <24 hrs before. Patient's VS are stable, and they're sitting up in bed chatting with their family. The cardiologist says he can't do anything with the patient until he has an EGD. (GI doc hasn't even seen the patient yet) We say fine - write a progress note that says this is an emergency, and if the GI doc wants to scope them, we can be back in 5 minutes with our equipment. The hemming and hawing starts immediately. We never heard another word the rest of the day.

We're not surgeons - we can't decide if their case is an "emergency" or not. But if they're declaring it an emergency, and we have a problem with it, then they should be willing to back up their claim by documenting it in the medical record. Having us document the conversation or the nurse document it in their record is pointless - surgeons will throw you under the bus in a heartbeat when **** hits the fan. CYA.

 

[anynoise]

i actually would probably put a spinal in the guy and not a drop of sedation and offer that to the patient and if he says no... then he goes home.. if he says yes the surgeon can do his case.. "you shouldnt have had the pudding sir"

I know what you are thinking.. well what if the spinal goes high.. and you have to intubate..

look at the guy if you think the spinal is a chip shot and the guy has a great airway... go for it


If you think it may be problematic and it may be a problem.. cancel the case. Use your judgement, thats what everyone is asking you to do

 

[powermd]

Why isn't the patient part of the risk/benefit discussion?

Perhaps if the patient were informed of the risks (after the fact), he/she might decline surgery until NPO guidelines are met. Problem solved!

On that subject, why isn't the patient allowed to consent to the risk of aspiration? I have some ideas on this, but I'd like to hear your comments.

If the patient wants both pudding and imminent surgery, and is willing to take an unknown (?) but likely low risk of death from aspiration PNA, why can't he take it? Realistically if you placed a spinal the odds of needing to manipulate the airway are low, and the odds of an aspiration event leading to PNA and then death are also likely low even if you had to go RSI.

 

[jwk]

Why isn't the patient part of the risk/benefit discussion?

Perhaps if the patient were informed of the risks (after the fact), he/she might decline surgery until NPO guidelines are met. Problem solved!

On that subject, why isn't the patient allowed to consent to the risk of aspiration? I have some ideas on this, but I'd like to hear your comments.

If the patient wants both pudding and imminent surgery, and is willing to take an unknown (?) but likely low risk of death from aspiration PNA, why can't he take it? Realistically if you placed a spinal the odds of needing to manipulate the airway are low, and the odds of an aspiration event leading to PNA and then death are also likely low even if you had to go RSI.

Because if the patient dies, the family will still sue, and regardless of the consent or lack thereof, you breached the standard of care.

 

[powermd]

Because if the patient dies, the family will still sue, and regardless of the consent or lack thereof, you breached the standard of care.

That would be the main reason we don't allow patients to consent to certain risks. Although patients consent to severe risks routinely. What makes this one special? It seems to me it would be the 'easily preventable' nature of this complication that puts it in a separate category from all the other severe complications a patient consents to as part of an operation. Thoughts?

You didn't address my first point, which was why not include the patient in the risk discussion so that if you get a "no" answer, it solves your problem with the surgeon. If you get a "yes", well then it's back to convincing the surgeon to declare the procedure emergent.

If I were the patient, I would want to know the surgeon was fudging the urgency of my surgery just to get the anesthesiologist to go along with his plan to operate under sub-optimal conditions. Independent of whatever reasons led to me violating the NPO order, I would be pissed the surgeon didn't put my well being above his need for scheduling convenience.

 

[ssmallz]

Postponing/canceling cases is all about the manor your choose and the words that you use to express them. As a resident one of my favorite attendings used to say "I've never cancelled a case in my life, I've just convinced surgeons to do it for me". That's the mentality that I think you need to have. Talk to the surgeon, express your concerns but put the ultimate burden on him.

"Dr. Surgeon, I know this guy only had a bite of pudding but the NPO guidelines are pretty clear and the risk of aspiration is significant. I'm always concerned about aspiration and possible post op intubation but if you declare this an emergency we can be in the OR ASAP."

By doing it this way you give the surgeon the option of going now and it put the onus on him rather than you. If he decides to proceed have him document it in the chart and you document it on the anesthesia record. Take the typical RSI precautions and hope for the best. The important thing is that if something does go wrong, you now have a leg to stand on when the lawyer says "Dr. Why did you violate the NPO guidelines of your hospital"

 

[Gasworks]

I'm sorry for my lack of understanding but what does the surgeon "declaring it an emergency" mean when something does actually go wrong? Is this something other than posturing on both parts or will it alter the decision on a malpractice settlement or in court?

 

[pgg]

I'm sorry for my lack of understanding but what does the surgeon "declaring it an emergency" mean when something does actually go wrong? Is this something other than posturing on both parts or will it alter the decision on a malpractice settlement or in court?

If you ignore NPO guidelines, do an elective case, and the patient aspirates you're going to have trouble defending your decision to not wait for the recommended period of time. I think this is as close to self-evident as anything in medicine is: ignore your professional society's guidelines at your own peril.

If the case is urgent or emergent, the surgeon is declaring in the medical recordthat it is not appropriate to give the underlying pathology some number of hours to sit there and cook. In this case, you're not ignoring the NPO guidelines, you and the surgeon are explicitly acknowledging them and making the judgment call that prompt surgery with its elevated aspiration risk is preferable than delayed surgery with (perhaps) reduced aspiration risk.

 

[cchoukal]

If the case is urgent or emergent, the surgeon is declaring in the medical recordthat it is not appropriate to give the underlying pathology some number of hours to sit there and cook. In this case, you're not ignoring the NPO guidelines, you and the surgeon are explicitly acknowledging them and making the judgment call that prompt surgery with its elevated aspiration risk is preferable than delayed surgery with (perhaps) reduced aspiration risk.

With the appropriate understanding of what "emergent" means. In my book, it is loss of life, limb, or vision. At our institution, the surgeons play pretty fast and loose with the term (and we should probably do a better job of calling them out on this).

 

[ssmallz]

With the appropriate understanding of what "emergent" means. In my book, it is loss of life, limb, or vision. At our institution, the surgeons play pretty fast and loose with the term (and we should probably do a better job of calling them out on this).

If they want to play fast and loose w/the definition of surgical emergency that's their issue. "Mr. Lawyer, I'm not a surgeon and I do not know what constitutes a surgical emergency. I have to trust Dr. Surgeon that when he says this case is a surgical emergency that it truly is"

 

[jwk]

If they want to play fast and loose w/the definition of surgical emergency that's their issue. "Mr. Lawyer, I'm not a surgeon and I do not know what constitutes a surgical emergency. I have to trust Dr. Surgeon that when he says this case is a surgical emergency that it truly is"

Exactly - and that's why it's important for the surgeon to document in the medical record that the case is an emergency, and not just have anesthesia or the circulator document that the discussion occurred. Make them sign their name to it and own it.

 

[anynoise]

By doing it this way you give the surgeon the option of going now and it put the onus on him rather than you. If he decides to proceed have him document it in the chart and you document it on the anesthesia record. Take the typical RSI precautions and hope for the best. The important thing is that if something does go wrong, you now have a leg to stand on when the lawyer says "Dr. Why did you violate the NPO guidelines of your hospital"

MOst surgeons care more about their scheduling convenience than the risk of aspiration. How is this a newsflash? If it was up to them nobody would get labs, xrays, nobody would be npo.. nothing.. Thats why we came along. Before us there wasnt us.. there was anyone who was close by to stand there and do what the surgeon wanted and many people died. So, No, it aint the surgeons call. PLay politics with him but ultimately if he wants to go ahead and you dont. DOnt do it.

 

[Surfer]

I've never seen an aspiration because somebody ate a "bite of pudding." In fact, i've never seen a regular person vomit on induction (traumas, emergency surgeries excluded). the NPO guidelines are bogus, just made up numbers with absolutely no science or evidence behind them.

you can aspirate with nothing in your belly (gastric secretions). I don't think a bite of pudding is going to do much damage to anybody's lungs even in the 1/1,000,000 chance it ends up there. That being said, I'm forced by my own bogus professional society to practice medicine according to THEIR guidelines instead of my own good judgment, so I wait, unless the surgeon says "its an emergency" and that's good enough for me. I'm not going to obsess over some note in the chart, you guys are nuts. I just write on my record, "surgeon declared case 'emergent' and could not wait after discussion of npo guidelines."

you guys worry too much.

 

[Surfer]

the funny thing is, i would be willing to bet somewhere between 10-25% of all the surgeries we do the patient is not truly npo. they just lie about it. i'm willing to bet most patients have a light breakfast the morning of surgery. nobody understands the rule, they think we're just being mean, so they lie about it. i remember hearing about a study like that, but haven't actually seen it.

 

[Arch Guillotti]

MOst surgeons care more about their scheduling convenience than the risk of aspiration. How is this a newsflash? If it was up to them nobody would get labs, xrays, nobody would be npo.. nothing..

I don't know, I see surgeons order plenty of unnecessary labs and studies.

 

[Arch Guillotti]

I've never seen an aspiration because somebody ate a "bite of pudding." In fact, i've never seen a regular person vomit on induction (traumas, emergency surgeries excluded). the NPO guidelines are bogus, just made up numbers with absolutely no science or evidence behind them.

you can aspirate with nothing in your belly (gastric secretions). I don't think a bite of pudding is going to do much damage to anybody's lungs even in the 1/1,000,000 chance it ends up there. That being said, I'm forced by my own bogus professional society to practice medicine according to THEIR guidelines instead of my own good judgment, so I wait, unless the surgeon says "its an emergency" and that's good enough for me. I'm not going to obsess over some note in the chart, you guys are nuts. I just write on my record, "surgeon declared case 'emergent' and could not wait after discussion of npo guidelines."

you guys worry too much.

probably true to at least some degree but we are all slaves to the guidelines and medicolegal fears.

 

[epidural man]

I've never seen an aspiration because somebody ate a "bite of pudding." In fact, i've never seen a regular person vomit on induction (traumas, emergency surgeries excluded). the NPO guidelines are bogus, just made up numbers with absolutely no science or evidence behind them.

you can aspirate with nothing in your belly (gastric secretions). I don't think a bite of pudding is going to do much damage to anybody's lungs even in the 1/1,000,000 chance it ends up there. That being said, I'm forced by my own bogus professional society to practice medicine according to THEIR guidelines instead of my own good judgment, so I wait, unless the surgeon says "its an emergency" and that's good enough for me. I'm not going to obsess over some note in the chart, you guys are nuts. I just write on my record, "surgeon declared case 'emergent' and could not wait after discussion of npo guidelines."

you guys worry too much.

BladeMD?

Where is that post where you link all those jury awards for aspiration?

Although I agree that the NPO guidelines are bogus - but we are stuck, and are essentially bound by them.

And I do agree that patients lie about that. More than one occasion, a Marine, in the haze of the awakening anesthesia would say in a mocking tone - "You guys told me not to eat, but HA! I had a hamburger before coming in!"

 

[MTGas2B]

I don't know, I see surgeons order plenty of unnecessary labs and studies.

A grouchy, old-school surgeon where I did my med student rotation was commenting about the podiatrist who operated at the hospital. "A doctor's confidence is inversely proportional to the number of pre-op labs ordered."

 

[Apollyon]

A grouchy, old-school surgeon where I did my med student rotation was commenting about the podiatrist who operated at the hospital. "A doctor's confidence is inversely proportional to the number of pre-op labs ordered."

Counterpoint: as I learned in military school, "There's a fine line between balls and stupidity".

 

[MTGas2B]

Counterpoint: as I learned in military school, "There's a fine line between balls and stupidity".

I don't live by his words. But I do find some truth in them.

 

[Oggg]

I don't know, I see surgeons order plenty of unnecessary labs and studies.

Heh heh. Surgeons order all the tests they can think of, blindly hoping that it will prevent case cancellation by the anesthesiologist

 

[jwk]

I've never seen an aspiration because somebody ate a "bite of pudding." In fact, i've never seen a regular person vomit on induction (traumas, emergency surgeries excluded). the NPO guidelines are bogus, just made up numbers with absolutely no science or evidence behind them.

you can aspirate with nothing in your belly (gastric secretions). I don't think a bite of pudding is going to do much damage to anybody's lungs even in the 1/1,000,000 chance it ends up there. That being said, I'm forced by my own bogus professional society to practice medicine according to THEIR guidelines instead of my own good judgment, so I wait, unless the surgeon says "its an emergency" and that's good enough for me. I'm not going to obsess over some note in the chart, you guys are nuts. I just write on my record, "surgeon declared case 'emergent' and could not wait after discussion of npo guidelines."

you guys worry too much.

Don't worry - you'll get burned sooner or later. And you're foolish to think surgeons won't throw you under the bus to save their own ass.

And what's this "bogus professional society" crap?

 

[Impromptu]

Postponed a case this week because he ate some Doritos 30 minutes before OR start time. I was picturing in my mind a flood of Doritos coming up the esophagus and down into the lung during intubation, not a pretty sight. The surgeons were actually understanding and stayed an hour later to do the case at the end of their other scheduled cases. This seemed like a good relationship.

 

[anynoise]

I've never seen an aspiration because somebody ate a "bite of pudding." In fact, i've never seen a regular person vomit on induction (traumas, emergency surgeries excluded). the NPO guidelines are bogus, just made up numbers with absolutely no science or evidence behind them.

you can aspirate with nothing in your belly (gastric secretions). I don't think a bite of pudding is going to do much damage to anybody's lungs even in the 1/1,000,000 chance it ends up there. That being said, I'm forced by my own bogus professional society to practice medicine according to THEIR guidelines instead of my own good judgment, so I wait, unless the surgeon says "its an emergency" and that's good enough for me. I'm not going to obsess over some note in the chart, you guys are nuts. I just write on my record, "surgeon declared case 'emergent' and could not wait after discussion of npo guidelines."

you guys worry too much.

patients do aspirate and you bet your ass that it is serious. I dont mind using your judgement that is actually what i think you should do. and I do think the npo guidelines(they are guidelines.. they are not rigid) are acceptable. If you feel they are bogus then by all means use your own guidelines but just be prepared to do some splainin' to whomever why you are not following guidelines widely accepted by everyone else. call your patients the night before and tell them they can have a light breakfast.

And about obsessing over charts... people much smarter than me and you have been burned .. When a plaintiffs attorney is reviewing the chart 1 year and 364 days from now it will be difficult to explain to him/her, and your peers why you have your own guidelines.


and what you call worry.. I call "risk reduction"

This a difficult job with many difficult problems.. npo is not one of the difficult dilemmas

 

[WholeLottaGame7]

the funny thing is, i would be willing to bet somewhere between 10-25% of all the surgeries we do the patient is not truly npo. they just lie about it. i'm willing to bet most patients have a light breakfast the morning of surgery. nobody understands the rule, they think we're just being mean, so they lie about it. i remember hearing about a study like that, but haven't actually seen it.

This would not surprise me in the least.

 

[Idiopathic]

I've never seen an aspiration because somebody ate a "bite of pudding." In fact, i've never seen a regular person vomit on induction (traumas, emergency surgeries excluded). the NPO guidelines are bogus, just made up numbers with absolutely no science or evidence behind them.

you can aspirate with nothing in your belly (gastric secretions). I don't think a bite of pudding is going to do much damage to anybody's lungs even in the 1/1,000,000 chance it ends up there. That being said, I'm forced by my own bogus professional society to practice medicine according to THEIR guidelines instead of my own good judgment, so I wait, unless the surgeon says "its an emergency" and that's good enough for me. I'm not going to obsess over some note in the chart, you guys are nuts. I just write on my record, "surgeon declared case 'emergent' and could not wait after discussion of npo guidelines."

you guys worry too much.

please post more

 

[Idiopathic]

the funny thing is, i would be willing to bet somewhere between 10-25% of all the surgeries we do the patient is not truly npo. they just lie about it. i'm willing to bet most patients have a light breakfast the morning of surgery. nobody understands the rule, they think we're just being mean, so they lie about it. i remember hearing about a study like that, but haven't actually seen it.

keep this stuff coming...if only there were some resource and searchable database to look for things like this.

 

[Surfer]

patients do aspirate and you bet your ass that it is serious. I dont mind using your judgement that is actually what i think you should do. and I do think the npo guidelines(they are guidelines.. they are not rigid) are acceptable. If you feel they are bogus then by all means use your own guidelines but just be prepared to do some splainin' to whomever why you are not following guidelines widely accepted by everyone else. call your patients the night before and tell them they can have a light breakfast.

And about obsessing over charts... people much smarter than me and you have been burned .. When a plaintiffs attorney is reviewing the chart 1 year and 364 days from now it will be difficult to explain to him/her, and your peers why you have your own guidelines.


and what you call worry.. I call "risk reduction"

This a difficult job with many difficult problems.. npo is not one of the difficult dilemmas

I. Never said I ignore the guidelines, I follow them. That these guides have become hard and fast, unbreakable rules is unfortunate. There is no science behind them at all.

Sure pts aspirate. I'm just saying gastric secretions are just as dangerous of not more so than a bite of pudding. Think about it! This is not a high risk for aspiration. But yes, I follow the guidelines, as dumb as they are.

 

[Surfer]

keep this stuff coming...if only there were some resource and searchable database to look for things like this.

That was an intelligent response. Do you believe Otherwise?? If so, where is your literature to prove it? Now prove the npo guidelines reduce mobidity... I'm waiting.

 

[Idiopathic]

im not challenging your opinion, just the way you formulate it. how many caes have you done? what is the actual frequency of aspiration? would you expect that your not seeing a case yet is an aberration, the norm, or expected, based upon your experience level?

also, to justify your grand statements with "i heard about a study once but havent read it" is CRNA-worthy

 

[cchoukal]

im not challenging your opinion, just the way you formulate it. how many caes have you done? what is the actual frequency of aspiration? would you expect that your not seeing a case yet is an aberration, the norm, or expected, based upon your experience level?

also, to justify your grand statements with "i heard about a study once but havent read it" is CRNA-worthy

I just gave a talk on this at a cme conference. Warner, Warner, and weber, 1996. Registry data. All comers: 1 in about 3200. There are other papers but this was a pretty big one.

 

[cincincyreds]

If the patient had the pudding at 1pm, I just tell the surgeon I will see him and the patient at 9pm unless he wants to find another anesthesiologist in my group to do the case. Otherweise, they can pound sand for 8 hours. I only practice for patient safety. I could care less what the surgeons want. I am not their friends and I am not there to satisfy them.

 

[epidural man]

and I do think the npo guidelines(they are guidelines.. they are not rigid) are acceptable.

I follow them. I have no leg to stand on if I don't.

However, I don't find them acceptable since there is no data or science to justify why they picked what they did. In fact, I think the numbers that are available are quit different from what we spew forth. The problem is, are there consequences for making patients wait a long time without eating or drinking?

Every intervention we make, there are consequences of those decisions. We often don't think about that. Honestly, I have no idea what they are in this case, but maybe they aren't as benign as we think they are.

I know that in the pain clinic we used to make EVERY patient be NPO for procedures even though sedation was extremely rare - and we had patients passing out ALL the time. I argued that it was absolutely ridiculous to do this since - and we have since change our policy (NPO only for neck procedures) and it has saved on glycopyrolate costs (and stress reduction 🙂)

 

[sevoflurane]

I have seen MASSIVE emesis on induction at least 5 times in my short career.

Trauma case. Resident accidentally goosed it. A smart attending MD(A) recognized this and:

1). Left the tube in the goose
2). Intubated said patient as Massive emesis literally shot out of the goosed tube... Prolly 800-1000ml. Good learning case.

Aspiration happens. It doesn't always cause a rip roaring pneumonitis.

However, I see no real benefit in placing yourself and your patient at risk.

Maybe the pudding is still there. Then you or your Crna/AA goosed them and pumped a good 1500ccs of air into the stomach before you pull out the tube (or not) and secure the AW. Will your patient aspirate in this scenario? Prolly not.

But is it worth it to you? What do you gain? What does your patient gain?

 

[epidural man]

Aspiration happens. It doesn't always cause a rip roaring pneumonitis.

👍

I'm a CA-1, SBO in an 81 y/o rolls in. I present my case to the attending - he changes my induction plan to use roc instead of sux. (Fine I guess, Roc apparently is used for RSI sometimes I thought.)

I suck out the NG before induction - can't remember if we removed it or not - anyway, upon pushing the roc and after what seemed like 10 seconds, my attending says - go ahead and put the tube in ...and I'm thinking to myself...Roc isn't sux ya know....but do as I am told. The guy bucks - massive amount of sheeeeit and bowel contents spew forth like nothing I have seen before - just an unbelievable amount of stuff - anyway, we get the tube in - and during the case, as they are milking the bowel and we have suction on FULL, stuff is pouring out the mouth, the nose - grosses thing ever. We placed another OG and had both tubes on high suction, but still couldn't keep up - stomach contents and bile everywhere (I still feel gross and icky describing it.)

Anyway, we bronch at the end - stuff all over the lungs. We suck and suck, keep the guy intubated and send to the ICU. They extubated him shortly after because he looked like a champ. After observing him for a while, kick him out of the unit since he looked so great. weeks later, I ask the chief resident surgeon about him - he says he went home looking great and looked good at the follow up - no signs of pneumonia. I couldn't believe it. His point was "sometimes those 80 y/o's just don't mount any immune response whatsoever."

I thought it was crazy.