What operations requires strict NPO?

[Doctadudeman]

I see surgeons order in NPO strict or NPO with meds and ice before surgeries, but there doesn’t seem to any obvious reason why they pick between the two. Some surgeons order NPO strict for laparoscopic cholecystectomy and others will be okay with ice and meds for the same procedure. I’m sure there are surgeries and risk factors that require strict NPO (bariatric, gastroparesis,etc), but is there any resources I can review to determine how this is figured out? Thanks in advance!

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[marblebeans]

It has more to do with anesthesia than surgery. Sips and meds are almost always OK if the anesthesiologist is comfortable. A big exception here is if you as the surgeon are worried about a high GI tract leak. Think esophageal anastomosis, gastric or duodenal perf, etc. You don't want much beyond some saliva leaking into the chest or abdomen. With high anesthesiologist turn over etc some people just order strict NPO but it's a bit arbitrary. Another consideration is when you make someone strict NPO you necessitate that everything is given IV. This is often advantageous when someone is on a lot of medicines (think needing to drink enough to swallow 10 pills TID) or when GI uptake/absorption is compromised (bowel obstructions, pancreatitis, etc). So making someone strict implies that they will get everything IV. It is annoying when I make someone NPO with sips for their comfort, only to find they are actually drinking more than a cup a day because all of their meds are given PO because they are not "strict". Hope this helps.

Reference: I'm an attending general surgeon

 

[LucidSplash]

The only time I order strict NPO is when the patient is already strict NPO for another (legitimate) reason, the patient is intubated, OR if it is an emergency procedure and I don’t want anything going down in an emergency. If they are already intubated, even though the airway is protected, I don’t want anyone putting down a med and clamping the NGT and sending them off for surgery and then maybe the NGT gets put to suction and they didn’t get a med that everyone thought they got but it was aspirated out.

Otherwise it’s always NPO except meds with sips for meds. Honestly I think newer data says clear up until a couple hours before is fine in most cases if you’re not doing upper GI tract surgery, but as stated above, not all anesthesiologists are on board with this and I don’t want my cases cancelled and I don’t always know who is covering the case from an anesthesia standpoint.

 

[longhaul3]

I am not a general surgeon but I also only order strict NPO for reasons not related to any surgery in particular. Patient can't safely swallow (by far the most common reason in neurosurgical patients), unstable orofacial fracture, recent ex-lap or pre-existing ileus or some other reason related to the GI tract

Otherwise NPO except meds. For kids usually clears until 2h prior to procedure, then NPO except meds, depending on the anesthesiologist

 

[DoctwoB]

There is no good reason patients can't have clears or meds before 99% of surgeries (I defer to you guys regarding esophageal/foregut work). There is some evidence we are delaying recovery by insisting on NPO.

The real reason is you never know which anesthesiologist you'll get, and you may get the crotchety old one who cancels your case based on 1980's dogma. So we cater to the lowest common denominator.

 

[TransformerInWestVirginia]

There is no good reason patients can't have clears or meds before 99% of surgeries (I defer to you guys regarding esophageal/foregut work). There is some evidence we are delaying recovery by insisting on NPO.

The real reason is you never know which anesthesiologist you'll get, and you may get the crotchety old one who cancels your case based on 1980's dogma. So we cater to the lowest common denominator.

agreed.
multiple of my attendings have emphasized this, backed by research and all. Sad that the paradigm hasn't shifted. alot of my program faculty are relatively young.

 

[Lem0nz]

Strict NPO is never necessary for surgery in my opinion, really ever. Ice chips and liquid medications even in upper GI surgery are not contra-indicated. If you know you're doing a staple line on the stomach you may not want pills the morning of surgery for a theoretical risk/fear of a pill in your staple line. That's about it.