Private practice NPO guidelines

[GaseousClay]

How often are you pp guys influenced by surgeons to stretch the NPO guidelines? Do you adhere strictly or do you find yourself bending the rules a bit to please the surgeons?

---

Members don't see this ad.

 

[amyl]

If there is a medical reason I'll break them.... Even if the reason is severe pain, etc. for surgeon convenience, no.

 

[pgg]

I only moonlight in PP but I don't stretch the guidelines. No reason to. I'm happy to do just about any case any time if the surgeon can document a plausible reason for urgency.

 

[pjl]

Never, unless it is "emergency"

If they were to aspirate one of the wonderful people in law would be happy to discuss why I broke the standard of care in that particular case in a courtroom setting.

Do surgeons sometimes get pissed? you bet.
Do I agree with the guidelines being correct? not completely

Still just not worth it for an elective case.

 

[chocomorsel]

Same as it was in academics for me unless we are talking about an emergency.
Actually in PP is where l learned that with a heavy meal, the recommendation was to wait 8 hours. I don't wait 8 hours unless the patient is fat and diabetic.

 

[pgg]

If there's any gray area it's maybe in what constitutes a "light" low fat meal (6 h) vs a full meal with fatty food (8 h).

 

[Mman]

PP NPO guidelines are the same as ASA NPO guidelines. If the surgeon really needs to do the case, simply write a note in the chart documenting the emergent nature of the procedure and the patient will be in the OR in 5 minutes.

 

[Direct Laryngoscopy]

Unfortunately where I work it is understood that NPO is for 6 hours. My department follows this and some surgeons look at 6 for the magic number. I will hold off for longer if there are circumstances that dictate such (heavy meal, DM, etc).

 

[Noyac]

Things that matter to me:
1) urgency of the case
2) health status of the pt and risks of aspiration
3) what was exactly eaten
4) time of the day ( I won't wait till midnight because someone had a small low fat meal 2-6 hrs ago)
5) other cases ready to go or waiting
6) surgeon needs ( this is last but it's still there).

 

[teeva]

For non-emergency cases, same as ASA guidelines 99.5% of the time.

The other 0.5% something stupid happens like an inpatient patient was served breakfast/lunch/dinner and literally ate a bite of it before someone realized pt was supposed to be NPO and took food away. Usually nurse and pt will confirm and agree on exactly how much was eaten. I'm more lenient in such circumstances and wait 4h. Reasons in PP for doing so are: logistical to keep OR schedule running, convenience for entire team/me/surgeon, not dumping cases onto the call person, not calling team back after hours or in the middle of the night.

If it were a pt who came from home, automatic cancellation, no exceptions.

 

[Ignatius J]

How often are you pp guys influenced by surgeons to stretch the NPO guidelines? Do you adhere strictly or do you find yourself bending the rules a bit to please the surgeons?

Find it kind of the opposite. The surgeon always automatically goes to 8 hours and doesn't even think about anything else. It's like a protocol burned into his brain. I do a lot more saying "It's okay, I don't care that he drank water four hours ago" type of stuff.

 

[caligas]

Interestingly our emergency medicine colleagues will happily give propofol and/or ketamine regardless of NPO status. They don't seem to have many problems as far as I can tell.

 

[periopdoc]

The accepted standard of care for their society is much different than ours. They will not be crucified for an aspiration event is in a non-NPO patient in the manner that we would. Our professional standards dictate that we abide by the NPO guidelines.

Like Teeva, I strictly follow the guidelines 99.5% of the time. My surgeons do not pressure me to break the guidelines. The obvious exception is the documented emergency situation (not an exception per se, but you know what I mean). I will also make allowances for a sip of water (it is allowed for patients taking meds that day what is the difference. If I delay a case, I do everything in my power to ensure that case goes without further delay. If I say wait six hours we are inducing six hours later not six hours 15 minutes later.

 

[Noyac]

Interestingly our emergency medicine colleagues will happily give propofol and/or ketamine regardless of NPO status. They don't seem to have many problems as far as I can tell.

That's because they are better at airway management than us.

 

[Noyac]

Periopdoc, you know I gotta ask what's so special about 15min? And don't tell me it the lawyers or the guidelines? If your pt aspirates you may be hosed no matter what.

Btw, I understand the gest of your comment.

 

[urge]

What I see every new and then is patients that had coffee with whole milk before checking in.
How long would you delay the case for a cup of coffee with whole milk? 6 hrs per guidelines? Would you even delay? How much milk is in there? Let's say it is a big case. Do you want to start a big case at 2pm? Is that better for the patient overall?

 

[deleted171991]

What I see every new and then is patients that had coffee with whole milk before checking in.

How long would you delay the case for a cup of coffee with whole milk? Would you even delay? How much milk is in there? Let's say it is a big case. Do you want to start a big case at 2pm? Is that better for the patient overall?

4-6 hours, depending on comorbidities. Yes, it's better for the patient, until proven otherwise (at which point the guidelines will probably change).

It's all a matter of probabilities. If one cuts corners enough times, one will get burned. The only question is when, not if. Every time I have been doing so well for a while that I feel almost cocky, something happens to remind me how thin the line I walk is. Nothing major, just enough to raise a flag when I think back at the end of the day.

There is another side to this: every time one almost gets burned, one learns something new about oneself, and something new that could actually help save another patient. My best reflexes were discovered when the **** hit the fan (maybe that's why I remember exactly what to do). Experience beats knowledge most of the time, and one won't learn new things if one never pushes the envelope. I am just not sure that every lesson is worth the risk.

With aspiration, specifically, the risks are high. People have died or suffered longstanding damage from something that started out as an aspiration.

 

[Skip2myLou]

I get that the ER society has less stringent NpO guidelines and it is considered normal the way they practice , but aspiration is an aspiration . I doubt the lawyers give a damn if your ER doc vs Gas guy . any studies analyzing aspirations with ER sedation vs anesthesia

 

[urge]

Thanks for moving your reply here.

4 hrs would not comply with guidelines.

Let's say you are doing an 8hr case. You are doing it to completion no matter what. Is it better to start it at 8am and finish at 4 or start at 2pm and finish at 10pm? That's something that needs to be considered too. After 14 hrs in the hospital your performance will not be the same. What's more dangerous, the milk, or being tired during the case?

 

[deleted171991]

4 hrs would not comply with guidelines.

That is correct. I should have said "depending on comorbidities, procedure, patient and surgeon". In a healthy and reliable patient who drank a cup of coffee with 50 cc of whole milk, I strongly doubt that it will take more than 3 hours for that stomach to be empty. If on top of this I have a simple procedure, such as a cataract, with a fast and reliable surgeon, you can bet I won't wait 6 hours.

Let's say you are doing an 8hr case. You are doing it to completion no matter what. Is it better to start it at 8am and finish at 4 or start at 2pm and finish at 10pm? That's something that needs to be considered too. After 14 hrs in the hospital your performance will not be the same. What's more dangerous, the milk, or being tired during the case?

That is a very good point. Unfortunately, it cannot be defended in the case of an elective surgery.

 

[urge]

. If on top of this I have a simple procedure, such as a cataract, with a fast and reliable surgeon, you can bet I won't wait 6 hours.

Wouldn't an intubated case be better if you are not following npo guidelines?

 

[deleted171991]

Wouldn't an intubated case be better if you are not following npo guidelines?

Not for a 10 minute-procedure with an awake patient.

 

[Pooh & Annie]

Not for a 10 minute-procedure with an awake patient.

Why are you there for a patient who's so awake that they don't need to follow npo guidelines? If they're getting a couple mg midaz, having you there is a waste of resources/money. If you're giving propofol for MAC though, you're playing with fire by not paying attention to guidelines.

 

[aneftp]

I'd love for anyone point to proven literature that says 8 hours npo. Like a real study.


I don't think they run npo studies on a large case basis since the 1960s and that was with healthy 150 pound 5'10 male medical students. And that study (which is what the Asa goes by) says 6 hours. This 8 hour rule is just a made up gray area.

An Asa "guidelines task force" is not the same as "standard of care" and this is the link saying 8 hours. But it's just opinion and not based on institutional large study.

http://www.asahq.org/~/media/Sites/...ctice-guidelines-for-preoperative-fasting.pdf

I've seen some split prep gi (drug sponsored) bs study saying majority of patients have less than 25cc of gastric contents left after a split prep colon prep within 2 hours. But again it's just bs when you look at their data their average weight of BOTH men and women were 180 pounds. Which we all know is very poor selection basis.

 

[aneftp]

Love to see where there is concrete evidence of this so called 8 hour rule. Notice they are very vague saying "some" may require 8 hours or more because of fatty intake.

 

[amyl]

I agree some of these guidelines are ??? But when something goes badly and you break them for an convenience reason what are you going to tell the Google-happy family member or opposing counsel.

 

[deleted171991]

Why are you there for a patient who's so awake that they don't need to follow npo guidelines? If they're getting a couple mg midaz, having you there is a waste of resources/money. If you're giving propofol for MAC though, you're playing with fire by not paying attention to guidelines.

I never give propofol during intraocular procedures. Strongly advise everybody not to (except for the initial block).

I completely agree that having an anesthesiologist for most cataract procedures (versed +/- fentanyl sedation) is a waste.

 

[Pooh & Annie]

We can probably leave the data out of it because I don't think anyone's arguing that they base their NPO practice on data. I'm guessing most of us would have been very comfortable doing cases that didn't quite meet guideline timelines. Unfortunately, even in someone who hasn't had anything for 24 hrs, there's a possibility of aspiration. Except in that case, folks won't be coming out of the woodwork to throw you under the bus.

 

[fakin' the funk]

How often are you pp guys influenced by surgeons to stretch the NPO guidelines? Do you adhere strictly or do you find yourself bending the rules a bit to please the surgeons?

Elective stuff, with NPO violations, surgeons IME are very conservative. Waiting, rescheduling/postponing are well received. Most of the time it's not even a question -- by the time the info is getting to us, the surgeon has already been notified and the case taken off the board.

With urgent stuff, surgeons IME are tolerant or willing to say a given case is an emergency (i.e. life or limb at risk, can't wait >6h) when that's not really, truly, strictly the case, to get the case started before 6h. Usually it's because they're worried about the patient and their surgical issue (say, a hand injury), moreso than just a convenience for the surgeon.