Volume of clear liquid

[keepassingas]

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Up to what volume do you consider okay for clear liquids prior to surgery? Couldn’t find anything definitive in my literature search. Saw a study that up to 10oz has little effect on gastric volume and pH.

 

[coffeebythelake]

Up to what volume do you consider okay for clear liquids prior to surgery? Couldn’t find anything definitive in my literature search. Saw a study that up to 10oz has little effect on gastric volume and pH.

What kind of time frame? If clears and greater than 2 hours I don't care. If less than 2 hours i hope it is in context of taking a sip with some necessary medication. Literature says significant aspiration can occur with volumes above 30 cc so I wouldn't want the patient to drink more than that volume.

 

[Simba1711]

Curious about this as well. Also with patients that chew gum. The data seems inconclusive.

 

[GassYous]

0.25 mL/kg and pH 2.5

 

[coffeebythelake]

0.25 mL/kg and pH 2.5

Yeah I remember significant aspiration occurijg with 25 cc, pH 2.5

 

[deleted1147063]

Up to what volume do you consider okay for clear liquids prior to surgery? Couldn’t find anything definitive in my literature search. Saw a study that up to 10oz has little effect on gastric volume and pH.

It's not just the studies that matter, it's also the standard of care of one's professional organization. Which, for the ASA, is 2 hours after clear liquids, and I don't remember it mentioning the amount. So I will accept taking some meds with a "sip" of water, because that's the departmental policy.

And the ASA says specifically that those are the standards for healthy patients, and one should increase the period if one suspects any reason for delayed gastric emptying.

 

[DrOwnage]

I usually don't care if they take a couple of sips with meds, if they're drinking the whole dixie cup I might be like whoa slow down. The truth is some people have gastric residual volumes even without drinking. How many times have you put in an OG and you get a decent amount out? I just put everyone head up for induction if I can and usually don't mask if I don't have to.

 

[coffeebythelake]

I usually don't care if they take a couple of sips with meds, if they're drinking the whole dixie cup I might be like whoa slow down. The truth is some people have gastric residual volumes even without drinking. How many times have you put in an OG and you get a decent amount out? I just put everyone head up for induction if I can and usually don't mask if I don't have to.

And what if it was a sedation case..?

Just because patients have some residual gastric volume doesn't mean you shouldn't worry about adding extra volume on top of that!

 

[deleted875186]

I face this regularly. If sedation case with no airway, or older patient with comirbidities or reason to have delayed gastric emptying, I’m more conservative. For healthy patients that drank “a few sips” or more than just a sip with meds, sometimes let it go, but often by the time they’re checked in and ready for surgery it’s near 2 hours anyway.

 

[deleted1147063]

I usually don't care if they take a couple of sips with meds, if they're drinking the whole dixie cup I might be like whoa slow down. The truth is some people have gastric residual volumes even without drinking. How many times have you put in an OG and you get a decent amount out? I just put everyone head up for induction if I can and usually don't mask if I don't have t

If there is a bad outcome, it won't matter what the patient did. It will matter what we did. If the patient told us that they had clears in the previous 2 hours and we didn't wait and they aspirated, guess what, we're liable. Especially in elderly, that could mean much more than just a minor pneumonitis. That's an immediate settlement level case.

People don't realize that aspiration can kill, especially older and sicker people. Even if it's just dilute bile or stomach acid. The problem is not just what they drink. The problem is what's already in their stomach. Until we gastric ultrasound everybody as part of a preop exam, I wouldn't be too cavalier with any amount of clears. Waiting 2 hours hasn't killed anybody.

 

[anesthesiadoc]

Curious about this as well. Also with patients that chew gum. The data seems inconclusive.

Gum was on my MOCA minute this week. Data says proceed (unless they swallowed it, I guess)

 

[LivetoTell]

What's the best approach to this scenario. It's 2100, OB calls and they have a pt with previous c-section that just came in with rupture of membranes, etc. The OB wants to know when they can section her. She had dinner at 2000. Do you wait till 0200 to do the section? How does the fact that pregnant women are considered full stomachs anyway, play into the mix?

 

[deleted1147063]

What's the best approach to this scenario. It's 2100, OB calls and they have a pt with previous c-section that just came in with rupture of membranes, etc. The OB wants to know when they can section her. She had dinner at 2000. Do you wait till 0200 to do the section? How does the fact that pregnant women are considered full stomachs anyway, play into the mix?

No. I wait till 0400. He can declare an emergency at any time, and I'll happily oblige (if reasonable, and not because of selfish reasons).

Just because a parturient needs full stomach precautions, we shouldn't actually make her one. It's called prudence.

My job is keeping my patients safe, not surgeons happy. I'd rather take a pay cut or change jobs (and I actually did).

I'm a consultant and a professional. I don't have a different opinion at 9 am and at 9 pm.

 

[Onefellswoop87]

Gum was on my MOCA minute this week. Data says proceed (unless they swallowed it, I guess)

It’s a 7 year delay if they swallow gum, right?

 

[deleted875186]

What's the best approach to this scenario. It's 2100, OB calls and they have a pt with previous c-section that just came in with rupture of membranes, etc. The OB wants to know when they can section her. She had dinner at 2000. Do you wait till 0200 to do the section? How does the fact that pregnant women are considered full stomachs anyway, play into the mix?

Delay. Now if patient is contracting and the OB thinks the risk of proceeding with labor with a prior CS is too high for some reason, than we can call it an emergency and go. Otherwise ruptured membrains are not an emergency.


I recently had a similar case, but patient had a prolapsed cord, so ultimately decided to just proceed. She had only been NPO 4 hours I believe after a full meal.

 

[Arch Guillotti]

I recently had a similar case, but patient had a prolapsed cord, so ultimately decided to just proceed. She had only been NPO 4 hours I believe after a full meal.

Has there ever been a prolapsed cord that didn't proceed directly to the OR?

 

[deleted875186]

Has there ever been a prolapsed cord that didn't proceed directly to the OR?

Fair point.

 

[pocafx]

Delay. Now if patient is contracting and the OB thinks the risk of proceeding with labor with a prior CS is too high for some reason, than we can call it an emergency and go. Otherwise ruptured membrains are not an emergency.


I recently had a similar case, but patient had a prolapsed cord, so ultimately decided to just proceed. She had only been NPO 4 hours I believe after a full meal.

GA?

 

[coffeebythelake]

GA?

why

 

[pocafx]

Well emergency as it is prolapsed cord. But also not NPO. This person doesn’t have epidural correct?

 

[Arch Guillotti]

Well emergency as it is prolapsed cord. But also not NPO. This person doesn’t have epidural correct?

Sometimes prolapsed cord needs to go to sleep even if they have an epidural unfortunately.

 

[IlDestriero]

We use 8/6hrs for food and 3 hours for breast milk, and 1 hour for clear fluids. Unless there are comorbidities, etc.
This is at a children’s hospital. The written guidelines use 4-6 Oz of clear liquid in the example.
I had one teenager say that he drank a 28oz Gatorade bottle on the way in. I made him wait until 2 hours from when he said he drank it.

In our practice a prolapsed cord would be an immediate crash C-section with GA.

 

[coffeebythelake]

We use 8/6hrs for food and 3 hours for breast milk, and 1 hour for clear fluids. Unless there are comorbidities, etc.
This is at a children’s hospital. The written guidelines use 4-6 Oz of clear liquid in the example.
I had one teenager say that he drank a 28oz Gatorade bottle on the way in. I made him wait until 2 hours from when he said he drank it.

In our practice a prolapsed cord would be an immediate crash C-section with GA.

Doesn't guidelines say 4 hrs for human breast milk? And 2 hr for clears? This modification is based on your group consensus? I don't know if that will hold up if a patient aspirates..

 

[IlDestriero]

It’s consistent with the European society and I think Australia as well for peds and many children’s hospitals in the US adopted it. We’ve actually been doing it for 5 years now.
I’m not worried about finding expert witnesses to say it meets the standard of care for uncomplicated peds.
I actually don’t know if the SPA released their own guidelines or not. They usually like to play nice with the ASA. This has been a subject of debate and discussion for a long time now in the peds world.

https://www.esaic.org/uploads/2022/01/pre_operative_fasting_in_children__a_guidelin.pdf

 

[DrAmir0078]

• In 2018, an international consensus statement was issued, advising a reduced fasting period for clear fluids to 1h (with a maximum volume of 3mL/ kg).
Reference:
Oxford Handbook of Anesthesia 5th edition 2022 - Chapter 3 Preoptimisation - Page 57 / Fasting.

I don't know if you like Oxford Handbook of Anesthesia !
It was almost my Bible in my final residency year.

 

[IlDestriero]

I don't know if you like Oxford Handbook of Anesthesia !
It was almost my Bible in my final residency year.

In the us we like to read our old dogma based review books that are on the 12th or 25th editions, not that newfangled garbage with its recent evidenced based chapters.

 

[DrAmir0078]

Yeah I remember significant aspiration occurijg with 25 cc, pH 2.5

In your practice, do you advise all your patients to have 0.3M Sodium citrate 30 ml immediately prior to GA?

I haven't seen it at all in my Country, but is it like bicitra cups used often in the ER in the US?

 

[DrAmir0078]

In the us we like to read our old dogma based review books that are on the 12th or 25th editions, not that newfangled garbage with its recent evidenced based chapters.

lol, what does that even mean? The old dogma US books you mean : Barash, Miller, Faust, Yao, Morgan,,, etc
I wished if I was able to stick with anyone of them, but our residency lacks a solid syllabus of confined textbook to relay on. We were lost man !
Oxford Handbook of Anesthesia is something concise and suits my needs 🙁

 

[fakin' the funk]

Up to what volume do you consider okay for clear liquids prior to surgery? Couldn’t find anything definitive in my literature search. Saw a study that up to 10oz has little effect on gastric volume and pH.

It's clears ad lib until 2 hours prior to anesthesia. Sips with meds after that, <30ml.

 

[coffeebythelake]

In your practice, do you advise all your patients to have 0.3M Sodium citrate 30 ml immediately prior to GA?

I haven't seen it at all in my Country, but is it like bicitra cups used often in the ER in the US?

Not all patients, but those who might be at risk for significant aspiration. I personally don't like bicitra because it tastes not great and I've had some patients retch and vomit when drinking it. I prefer iv pepcid 30 min before surgery

A patient aspirating a slightly bigger volume of bicitra-buffered stomach acid is goijg to be less dangerous than a slightly small volume of pH <2.5 stomach acid.

 

[LaryngoSpazz]

Not all patients, but those who might be at risk for significant aspiration. I personally don't like bicitra because it tastes not great and I've had some patients retch and vomit when drinking it. I prefer iv pepcid 30 min before surgery

A patient aspirating a slightly bigger volume of bicitra-buffered stomach acid is goijg to be less dangerous than a slightly small volume of pH 2.5 stomach acid.

It does taste terrible but it’s more than done it’s job when the patient vomits after drinking it.

I don’t routinely use it except for c sections

 

[coffeebythelake]

any of you give bicitra in bowel obstruction cases? seems like a drop in the ocean

 

[nimbus]

I haven’t given bicitra since I stopped doing OB in 2005.

 

[GassYous]

any of you give bicitra in bowel obstruction cases? seems like a drop in the ocean

Well considering the problem is an obstruction...

 

[deleted875186]

any of you give bicitra in bowel obstruction cases? seems like a drop in the ocean

I don’t give anything in SBO patients, but maybe I should. If they’re getting GA they usually have a NG which I try to aggressively suction and then do a true RSI.

 

[Greenbayslacker]

He can declare an emergency at any time, and I'll happily oblige .

Genuine question, does declaring a case as an emergency somehow absolve you of liability? For example if the patient aspirated respite NGT, RSI & cricoid

 

[GassYous]

Genuine question, does declaring a case as an emergency somehow absolve you of liability? For example if the patient aspirated respite NGT, RSI & cricoid

Cricoid doesn't help and maybe hurts

 

[epidural man]

Genuine question, does declaring a case as an emergency somehow absolve you of liability? For example if the patient aspirated respite NGT, RSI & cricoid

Yes (I would say)

Why would you be held liable if someone who just ate a hamburger who now has an open wound bleeding to death aspirated on induction?

 

[deleted1147063]

Genuine question, does declaring a case as an emergency somehow absolve you of liability? For example if the patient aspirated respite NGT, RSI & cricoid

Yes. If the outcome is bad, but you followed the standard of care, you are not liable (it's not dereliction of duty).

One can do everything perfectly, and still the outcome could be bad. And the other way round. That's why we say: better lucky than good.

 

[coffeebythelake]

Genuine question, does declaring a case as an emergency somehow absolve you of liability? For example if the patient aspirated respite NGT, RSI & cricoid

Yes, but I foresee the lawyers picking at whether the "emergency" was truly an emergency or not. I am not a surgical expert. I don't know if a case necessarily needs to roll asap even at the increased risk for aspiration. Maybe this spreads the blame and liability to the surgeon who made that call.