particulate antacids and NPO

[Mister Mxyzptlk]

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Can someone give me a reference on why you need to wait 6-8 hours after taking a particulate antacid like Tums or Rolaids? Preferably something scientific and not just a recommendation based on theory.

 

[Mman]

since none of our NPO guidelines have much in the way of scientific evidence I doubt you find anything meaningful

 

[Mister Mxyzptlk]

I doubt it too, but an anesthesiologist just screwed me on a MAC case because the patient took a Tums at 3 a.m. for a 7:30 case. They wanted to postpone until 9 a.m., which was not feasible for me since I have a full schedule in the office.

I did gas for 20 years before going 100% pain and I usually go with whatever the anesthesiologist is comfortable with but this is crazy. During my academic incarnation I published and lectured on the topic so I know how soft the data are and how ridiculous the criteria of "2.5 and 30" are.

I was told that "this is what we're taught at every course", i.e., that after a particulate antacid you have to wait 6 hours. I've been all over the Internet and PubMed and I can't find anything at all to support this.

 

[medking]

Dogma is so much fun!

 

[Mister Mxyzptlk]

Here's the answer from a 10th grader.

 

[Mman]

My only rationale for my stance would be that patients can take meds with a sip of water preop. Tums is a med. If they had reflux and took it I wouldn't bat an eye, but I'd probably give them some bicitra and do an RSI. I don't like MACs on patients complaining of bad reflux. They get a tube.

 

[Colba55o]

I doubt it too, but an anesthesiologist just screwed me on a MAC case because the patient took a Tums at 3 a.m. for a 7:30 case. They wanted to postpone until 9 a.m., which was not feasible for me since I have a full schedule in the office.

I did gas for 20 years before going 100% pain and I usually go with whatever the anesthesiologist is comfortable with but this is crazy. During my academic incarnation I published and lectured on the topic so I know how soft the data are and how ridiculous the criteria of "2.5 and 30" are.

I was told that "this is what we're taught at every course", i.e., that after a particulate antacid you have to wait 6 hours. I've been all over the Internet and PubMed and I can't find anything at all to support this.

The anesthesiologist didnt't screw you, the patient did. If patient aspirated, you know you would have thrown him/her under the bus and pointed to NPO guidelines 🙄

 

[Mister Mxyzptlk]

Bullshoot. I don't "know" any such thing. I wouldn't do that to a colleague. Maybe you're the kind of person who thinks of doing things like that but don't project your sick thoughts onto others.

Another reason I wouldn't throw someone under the bus for that is because there are no NPO guidelines for someone who has taken a particulate antacid. Zero, zilch, nada.

It's calcium carbonate, not gravel. It's like delaying surgery 6 hours for drinking an Alka-Seltzer. It dissolves.

 

[pgg]

Here's the answer from a 10th grader.

Maybe she can do your case.

Worst case, I could buy the argument that a PO med + a sip of water is a clear liquid, requiring two hours. I think cancelling was silly.

Best case, you start telling your patients that the most important part of NPO is the N ... and then you won't be at the mercy of your anesthesiologist's interpretation of the NPO guidelines.

 

[Mman]

Maybe she can do your case.

Worst case, I could buy the argument that a PO med + a sip of water is a clear liquid, requiring two hours. I think cancelling was silly.

You don't give patients oral pre-meds within 2 hours of surgery?

 

[Planktonmd]

The anesthesiologist obviously doesn't like you and that's the question you should be asking yourself: Why does the anesthesiologist hate me???
It's usually something to do with attitude or arrogance!

 

[Mister Mxyzptlk]

Maybe she can do your case.

Worst case, I could buy the argument that a PO med + a sip of water is a clear liquid, requiring two hours. I think cancelling was silly.

Best case, you start telling your patients that the most important part of NPO is the N ... and then you won't be at the mercy of your anesthesiologist's interpretation of the NPO guidelines.

Ohhh. I should START telling the patients to be NPO? I knew I was forgetting something.

A PO med, singular? How about the people who take 5-10 pills and are still considered good to go?

Maybe I should get the 10th grader to do the case. She shows some signs of intelligence and not just blind superstition. I'll bet she could figure out that if the upper bound of safety is 30 mL and you give someone 30 mL of liquid antacid, there goes the whole deal.

As if there's something magically safe about 29 mL that doesn't happen at 31 mL, or that a pH of 2.4 is lethal but 2.6 is not. If you agree that these cut-offs are bogus there goes 99% of your literature on aspiration risk.

Have you ever looked at where these numbers come from? You know the one about 0.4 mg/kg? That is the volume of intra-tracheal acid they gave to rabbits.

Actually the anesthesiologist and I are good friends and when we opened the facility I recruited her and her group. Last year when I was in Italy I picked up a rosary for her. This is the first time in 10 years working together that I have disagreed with her. She doesn't hate me. Are you accusing her of being mean and spiteful and interfering with a patient's care to spite the surgeon?

Where do you come up with this stuff? Is that how you act at work?

 

[Planktonmd]

Actually the anesthesiologist and I are good friends and when we opened the facility I recruited her and her group. Last year when I was in Italy I picked up a rosary for her. This is the first time in 10 years working together that I have disagreed with her. She doesn't hate me. Are you accusing her of being mean and spiteful and interfering with a patient's care to spite the surgeon?

Where do you come up with this stuff? Is that how you act at work?

Who's the surgeon? you? Didn't you say that you are an anesthesiologist who decided to go exclusively pain 20 years ago?
When did you become a surgeon???
But that's probably why she hates you and wants to cancel your case for this silly reason! You are a pretend surgeon 😉 and you are obviously an attractive target to apply all the stupid and dogmatic rules!

 

[Urzuz]

Getting back to the discussion at hand, anyone who wants to wait 6-8 hours following a Tums is an idiot.

Keep in mind the patient had been NPO for 4.5 hours following the Tums and the anesthesiologist still wanted to delay it...

 

[pgg]

You don't give patients oral pre-meds within 2 hours of surgery?

Sure. They can take it in holding before we roll to the OR. We used to give PO acetaminophen, gabapentin, and celecoxib in holding as part of our total joint protocol.

Others called it a clear liquid and insisted that the patients get it as soon as they checked in to day surgery, so they'd have 2 hours prior to surgery start. I thought that was silly, but they were the ones doing the case. Which is why I used the phrase "worst case" in my post.

To be clear, I wouldn't have cancelled this case and I don't think anyone I work with would have, either.

 

[pgg]

Ohhh. I should START telling the patients to be NPO? I knew I was forgetting something.

A PO med, singular? How about the people who take 5-10 pills and are still considered good to go?

Maybe I should get the 10th grader to do the case. She shows some signs of intelligence and not just blind superstition. I'll bet she could figure out that if the upper bound of safety is 30 mL and you give someone 30 mL of liquid antacid, there goes the whole deal.

As if there's something magically safe about 29 mL that doesn't happen at 31 mL, or that a pH of 2.4 is lethal but 2.6 is not. If you agree that these cut-offs are bogus there goes 99% of your literature on aspiration risk.

Have you ever looked at where these numbers come from? You know the one about 0.4 mg/kg? That is the volume of intra-tracheal acid they gave to rabbits.

Actually the anesthesiologist and I are good friends and when we opened the facility I recruited her and her group. Last year when I was in Italy I picked up a rosary for her. This is the first time in 10 years working together that I have disagreed with her. She doesn't hate me. Are you accusing her of being mean and spiteful and interfering with a patient's care to spite the surgeon?

Where do you come up with this stuff? Is that how you act at work?

If you're this grouchy and bitchy a "surgeon" at work, I could understand why someone would avoid doing cases with you.

To be clear, I wouldn't have cancelled your case or required 6 hours since the Tums.

 

[pgg]

Here's the answer from a 10th grader.

Maybe she can do your case.

I didn't think this was subtle enough to require a smiley to show I wasn't serious, but I guess it went over your head.

🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂

That oughta do it. Lighten up, Francis.

 

[lobelsteve]

I didn't think this was subtle enough to require a smiley to show I wasn't serious, but I guess it went over your head.

🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂 🙂

That oughta do it. Lighten up, Francis.

He is used to the pain forums where it is always a battle royale. Wrong bandaid choice for the procedure will get you burned in effigy, 10G to the heart.

 

[teeva]

It sounds silly to delay, but what procedure was it and what kind of anesthesia was required (not that it really matters anyway)?

 

[IlDestriero]

Studies have shown that aspiration of particulate antacid is particularly harmful, is that not still the case? That's what I learned back in the day and is why we use bicitra vs tums.
Kids don't take tums, so I'm not up on the literature these days.

 

[jwk]

Studies have shown that aspiration of particulate antacid is particularly harmful, is that not still the case? That's what I learned back in the day and is why we use bicitra vs tums.
Kids don't take tums, so I'm not up on the literature these days.

This is like old school stuff. Back when Maalox, etc., were the only antacids available (like pre-Zantac), we were well aware that aspiration of particulate antacids was a bad thing. Sand in your alveoli was, and I assume still is, thought to be evil.