Stupid NPO Guideline Question.....

[Iso4ane]

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For the ASA NPO guidelines would you consider Jello a clear liquid? If not what about honey and better thickened liquids? At what point is it no longer a liquid?

I guess the simple answer would be no, but 6-8 hours NPO for a guy who accidentally ate a Jello cup seems a little long.

 

[anesthesiadoc]

Jello has historically been thought of as a clear. Thickened liquids are going to act thick in the stomach and the lungs. I'd do at least 6 for honey thickened, 8 hours for Ensure/ high calorie feeds


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[leaverus]

Jello has historically been thought of as a clear. Thickened liquids are going to act thick in the stomach and the lungs. I'd do at least 6 for honey thickened, 8 hours for Ensure/ high calorie feeds


Sent from my iPhone using SDN mobile

that seems pretty arbitrary. I would think stomach acid would thin up honey pretty quickly - id wait 2.16hrs for honey. who the heck eats plain honey by itself anyway??

 

[twoliter]

that seems pretty arbitrary. I would think stomach acid would thin up honey pretty quickly - id wait 2.16hrs for honey. who the heck eats plain honey by itself anyway??

Not sure if serious, but...
Honey thickened. As in, food/drink thickened to the consistency of honey.

(Apologies in advance if sarcasm font wasn't picked up.)

 

[BLADEMDA]

For the ASA NPO guidelines would you consider Jello a clear liquid? If not what about honey and better thickened liquids? At what point is it no longer a liquid?

I guess the simple answer would be no, but 6-8 hours NPO for a guy who accidentally ate a Jello cup seems a little long.

I use 6 hours for any "light meal" if no other medical conditions like gastroparesis, etc. So, I'd treat Jello as a clear liquid and that means 2 hours (which is very conservative IMHO).

NPO Status and Aspiration

http://www.nyee.edu/files/NYEE/Health Professionals/Admitting Forms/adm-npo-guidelines.pdf

 

[BLADEMDA]

NO FOOD OR DRINK AFTER MIDNIGHT BEFORE SURGERY? NOT SO FAST, EXPERTS SAY
The old standby of no food or drink after midnight is getting a fresh look.

No food or drink after midnight before surgery? Not so fast, experts say | MHealth.org

 

[deleted171991]

Jello has historically been thought of as a clear. Thickened liquids are going to act thick in the stomach and the lungs. I'd do at least 6 for honey thickened, 8 hours for Ensure/ high calorie feeds


Sent from my iPhone using SDN mobile

I would love to see how Jello looks on gastric ultrasound.

 

[Mman]

jello is a clear, 2 hours, i mean hell if the patient is on a clear diet they get jello on their tray

 

[WholeLottaGame7]

I was always taught Jell-o is not a clear as it has gelatin in it. But a cursory glance of other institutional guidelines does consider it a clear, however, and Mman makes a good point, it comes on a CLD food tray.

Regardless, just remember, they're guidelines, not mandates.

 

[Iso4ane]

NO FOOD OR DRINK AFTER MIDNIGHT BEFORE SURGERY? NOT SO FAST, EXPERTS SAY
The old standby of no food or drink after midnight is getting a fresh look.

No food or drink after midnight before surgery? Not so fast, experts say | MHealth.org

I know the NPO after midnight is kind of bull****, but the way I see it if you are inpatient, unless you are first start, you pretty much don't know when you are going to the OR, so NPO from midnight seem like the simplest way to make sure everyone is compliant. I think it like speed limits, you know people are going to test those limits, might as well make it hyper-conservative.

jello is a clear, 2 hours, i mean hell if the patient is on a clear diet they get jello on their tray

Clear yes, liquid..maybe-ish. That's why I asked the question. Black Coffee isn't transparent (which what people think when we say the word clear). but black coffee is an clear liquid.

 

[propadope]

Jello is a solid at room temperature but melts at body temperature. It should be considered a liquid no?

If a patient takes a gel cap with a small sip of water you wouldn't wait 6-8 hours...

 

[Orin]

NPO after midnight but cases start at 0730 in a lot of places. Do you guys wait 30 minutes before inducing?

 

[fakin' the funk]

NPO after midnight but cases start at 0730 in a lot of places. Do you guys wait 30 minutes before inducing?

In my experience, patients often have their normal dinner (5-7pm the night before) and that's it. There's not a big group of patients out there finishing a burrito at 11:59:59 PM. Or, at least that's what they say...

Our group generally adheres to 6 hours regardless, unless the specific anesthesiologist has concerns about gastric emptying in that particular patient. When patients do "forget" and eat something, it's usually like juice or milk or something that would count as a "light meal."

 

[BLADEMDA]

Preoperative Fasting Guidelines: Why Are We Not Following Them?: The Time to Act Is NOW
Abola, Ramon E. MD; Gan, Tong J. MD, MHS, FRCA

Anesthesia & Analgesia:
April 2017 - Volume 124 - Issue 4 - p 1041–1043

Editorials: Editorial

• These practices have been recommended by the American Society of Anesthesiologists preoperative fasting guidelines since 1999. Therefore, the question is “why are not we doing this?” The accompanying manuscript by Shiraishi et al2 provides evidence that you should feel safe in allowing your patients to do so. The interesting questions that follow are (1) What should patients drink preoperatively? (2) What are the outcome benefits of preoperative oral hydration?
  
  In this trial, magnetic resonance imaging studies were conducted preoperatively to measure gastric volumes. The study enrolled 10 normal weight and 10 morbidly obese patients (average body mass index 45 kg/m2). After a 9-hour fast, the morbidly obese patient had larger volumes of gastric content (73 vs 31 mL). However, 2 hours after drinking 500 mL of a carbohydrate beverage (OS-1), stomach volumes had returned to baseline levels (50 and 30 mL) in both the obese and nonobese patients, respectively. In fact, gastric content volume was significantly lower at 2 hours after fluid ingestion than that at preingestion, after a 9-hour fast, in the morbidly obese group. This study suggests that gastric emptying may not be delayed in the morbidly obese, and a preoperative carbohydrate beverage decreases gastric volume in these patients compared with an overnight fast.

Gastric Fluid Volume Change After Oral Rehydration Solution Intake in Morbidly Obese and Normal Controls: A Magnetic Resonance Imaging-Based Analysis
Shiraishi, Toshie; Kurosaki, Dai; Nakamura, Mitsuyo; More

Anesthesia & Analgesia . 124(4):1174-1178, April 2017.

 

[MediCane2006]

Hi y'all. I lurk a lot in here because I love learning about what goes on across the drapes.

Posting in here for my own learning regarding a case today (identifying details changed, essentials aren't). 60's male, 1ppd smoker otherwise healthy (no reflux or COPD), going to the hoop for a big chest wall basal cell carcinoma. OR start was 0730, patient disclosed he had had a cup of coffee with a splash of cream at 0230.

Anesthesiologist decided to delay the case till 1030 to give him a full 8 hours NPO. I obviously wasn't going to argue, as it's not my bailiwick, but a few of my more senior partners were saying I should have pushed to start the case on time. I did a lit search this evening, fairly unfruitfully, but was curious as to the opinions of some of the old hands on this board (both for my own education and so I can teach my residents what's appropriate).

As an aside, I want to commend your board for being an entertaining and educational space where I always learn something new.....

 

[twoliter]

Hi y'all. I lurk a lot in here because I love learning about what goes on across the drapes.

Posting in here for my own learning regarding a case today (identifying details changed, essentials aren't). 60's male, 1ppd smoker otherwise healthy (no reflux or COPD), going to the hoop for a big chest wall basal cell carcinoma. OR start was 0730, patient disclosed he had had a cup of coffee with a splash of cream at 0230.

Anesthesiologist decided to delay the case till 1030 to give him a full 8 hours NPO. I obviously wasn't going to argue, as it's not my bailiwick, but a few of my more senior partners were saying I should have pushed to start the case on time. I did a lit search this evening, fairly unfruitfully, but was curious as to the opinions of some of the old hands on this board (both for my own education and so I can teach my residents what's appropriate).

As an aside, I want to commend your board for being an entertaining and educational space where I always learn something new.....

I would've gone for 6 hours, but nearly everything is gray area. I can't fault the guy too much. I'm sure some wouldn't have postponed at all.
Wait, he was drinking coffee at 2:30 am?

 

[MediCane2006]

I would've gone for 6 hours, but nearly everything is gray area. I can't fault the guy too much. I'm sure some wouldn't have postponed at all.
Wait, he was drinking coffee at 2:30 am?

that is of course the better question.... I love my patient population but sometimes I just have to shake my head.

 

[Arch Guillotti]

Hi y'all. I lurk a lot in here because I love learning about what goes on across the drapes.

Posting in here for my own learning regarding a case today (identifying details changed, essentials aren't). 60's male, 1ppd smoker otherwise healthy (no reflux or COPD), going to the hoop for a big chest wall basal cell carcinoma. OR start was 0730, patient disclosed he had had a cup of coffee with a splash of cream at 0230.

Anesthesiologist decided to delay the case till 1030 to give him a full 8 hours NPO. I obviously wasn't going to argue, as it's not my bailiwick, but a few of my more senior partners were saying I should have pushed to start the case on time. I did a lit search this evening, fairly unfruitfully, but was curious as to the opinions of some of the old hands on this board (both for my own education and so I can teach my residents what's appropriate).

As an aside, I want to commend your board for being an entertaining and educational space where I always learn something new.....

Not an entirely clear answer here although there are plenty of blowhards out there that would insist on 8 hours.

6 hours is probably reasonable.

 

[epidural man]

Preoperative Fasting Guidelines: Why Are We Not Following Them?: The Time to Act Is NOW
Abola, Ramon E. MD; Gan, Tong J. MD, MHS, FRCA

Anesthesia & Analgesia:
April 2017 - Volume 124 - Issue 4 - p 1041–1043

Editorials: Editorial

• These practices have been recommended by the American Society of Anesthesiologists preoperative fasting guidelines since 1999. Therefore, the question is “why are not we doing this?” The accompanying manuscript by Shiraishi et al2 provides evidence that you should feel safe in allowing your patients to do so. The interesting questions that follow are (1) What should patients drink preoperatively? (2) What are the outcome benefits of preoperative oral hydration?
  
  In this trial, magnetic resonance imaging studies were conducted preoperatively to measure gastric volumes. The study enrolled 10 normal weight and 10 morbidly obese patients (average body mass index 45 kg/m2). After a 9-hour fast, the morbidly obese patient had larger volumes of gastric content (73 vs 31 mL). However, 2 hours after drinking 500 mL of a carbohydrate beverage (OS-1), stomach volumes had returned to baseline levels (50 and 30 mL) in both the obese and nonobese patients, respectively. In fact, gastric content volume was significantly lower at 2 hours after fluid ingestion than that at preingestion, after a 9-hour fast, in the morbidly obese group. This study suggests that gastric emptying may not be delayed in the morbidly obese, and a preoperative carbohydrate beverage decreases gastric volume in these patients compared with an overnight fast.

Gastric Fluid Volume Change After Oral Rehydration Solution Intake in Morbidly Obese and Normal Controls: A Magnetic Resonance Imaging-Based Analysis
Shiraishi, Toshie; Kurosaki, Dai; Nakamura, Mitsuyo; More

Anesthesia & Analgesia . 124(4):1174-1178, April 2017.

I wonder why anyone would think a morbidly obese person would have gastric emptying problems. OBVIOUSLY, things move through just fine. IN fact, I think others have found (what you would expect) that morbid obesity people have FASTER emptying times. I know the morbid obese people I know get very hungry very quickly after a big meal.

 

[Dejavu]

Trouble is, if you have established, institutional, guidelines that spell out NPO rules, and you violate your own rules, wouldn't you hate to hear, " So, Doctor, read these rules from your institution and then tell the jury why you chose to violate your own rules."

On a different note, we have been giving pts a handful of pills on their way to the OR, as part of an analgesic pathway, for 15 or so years now, without any untoward results. Go figure.

 

[nimbus]

As a specialty, we need to revisit the NPO guidelines. 6 hrs is probably no more risky than 8 hrs for anybody.

 

[nimbus]

Preoperative Fasting Guidelines: Why Are We Not Following Them?: The Time to Act Is NOW
Abola, Ramon E. MD; Gan, Tong J. MD, MHS, FRCA

Anesthesia & Analgesia:
April 2017 - Volume 124 - Issue 4 - p 1041–1043

Editorials: Editorial

• These practices have been recommended by the American Society of Anesthesiologists preoperative fasting guidelines since 1999. Therefore, the question is “why are not we doing this?” The accompanying manuscript by Shiraishi et al2 provides evidence that you should feel safe in allowing your patients to do so. The interesting questions that follow are (1) What should patients drink preoperatively? (2) What are the outcome benefits of preoperative oral hydration?
  
  In this trial, magnetic resonance imaging studies were conducted preoperatively to measure gastric volumes. The study enrolled 10 normal weight and 10 morbidly obese patients (average body mass index 45 kg/m2). After a 9-hour fast, the morbidly obese patient had larger volumes of gastric content (73 vs 31 mL). However, 2 hours after drinking 500 mL of a carbohydrate beverage (OS-1), stomach volumes had returned to baseline levels (50 and 30 mL) in both the obese and nonobese patients, respectively. In fact, gastric content volume was significantly lower at 2 hours after fluid ingestion than that at preingestion, after a 9-hour fast, in the morbidly obese group. This study suggests that gastric emptying may not be delayed in the morbidly obese, and a preoperative carbohydrate beverage decreases gastric volume in these patients compared with an overnight fast.

Gastric Fluid Volume Change After Oral Rehydration Solution Intake in Morbidly Obese and Normal Controls: A Magnetic Resonance Imaging-Based Analysis
Shiraishi, Toshie; Kurosaki, Dai; Nakamura, Mitsuyo; More

Anesthesia & Analgesia . 124(4):1174-1178, April 2017.

Nobody is following them because they don't reflect reality.

 

[twoliter]

As a specialty, we need to revisit the NPO guidelines. 6 hrs is probably no more risky than 8 hrs for anybody.

That's sorta what the guidelines say. The 8 hours is for fatty, fried food. Granted, that's 90 percent of the diet for 90 percent of our patients, but 6 hours is still an option for a lot of food. (Completely anecdotal, but) I know I wake up still belching whatever the heck I ate the night before if it was a big fattening meal. I'm overweight, but don't have any other reason to have prolonged gastric emptying time. And the article above says that not even obesity matters all that much. Not that I completely agree with a study with a total N = 20.

 

[Arch Guillotti]

" So, Doctor, read these rules from your institution and then tell the jury why you chose to violate your own rules."

I don't worry about that really.

I think a bigger issue is inconsistency amongst anesthesiologists, especially when it comes to surgeons.

 

[WholeLottaGame7]

Hi y'all. I lurk a lot in here because I love learning about what goes on across the drapes.

Posting in here for my own learning regarding a case today (identifying details changed, essentials aren't). 60's male, 1ppd smoker otherwise healthy (no reflux or COPD), going to the hoop for a big chest wall basal cell carcinoma. OR start was 0730, patient disclosed he had had a cup of coffee with a splash of cream at 0230.

Anesthesiologist decided to delay the case till 1030 to give him a full 8 hours NPO. I obviously wasn't going to argue, as it's not my bailiwick, but a few of my more senior partners were saying I should have pushed to start the case on time. I did a lit search this evening, fairly unfruitfully, but was curious as to the opinions of some of the old hands on this board (both for my own education and so I can teach my residents what's appropriate).

As an aside, I want to commend your board for being an entertaining and educational space where I always learn something new.....

Are you sure you're a surgeon? You seem far too reasonable. Are you sure you didn't freak out first and cover the anesthesia machine with EKG stickers?

Would have voted for 6 hours, also. But, also realize that a lot of us are highly skeptical of patient-reported PO intake. "A couple sips of Mtn Dew" usually means 64oz, "a few fries" usually means a full Big Mac meal, etc.

 

[MediCane2006]

Are you sure you're a surgeon? You seem far too reasonable. Are you sure you didn't freak out first and cover the anesthesia machine with EKG stickers?

Would have voted for 6 hours, also. But, also realize that a lot of us are highly skeptical of patient-reported PO intake. "A couple sips of Mtn Dew" usually means 64oz, "a few fries" usually means a full Big Mac meal, etc.

Fair enough. And yeah, I try to avoid the stereotype 😉 mostly because I've got enough to worry about in most cases without trying to also second-guess everything the other board-certified physician in the room is doing.

 

[Arch Guillotti]

Usually when I get these calls from the nurses I am elbows-deep in other tasks. Unless I am told specifically told that the patient had a double-whopper with cheese on the way in for a truly elective case, 6 hors is usually reasonable. Give pepcid, raglan, etc. if needed.

 

[deleted171991]

Nobody is following them because they don't reflect reality.

The malpractice lawyers are following them. 😉