What's your policy?

[DrOwnage]

---

Members do not see this ad.

Recently I've had more patients eating the day of their elective surgeries. The ASA states an 8 hour NPO prior to procedure time.

Our patients are usually told their arrival time to the surgery center/hospital, and not their surgery start time. However, nurses that call the night before are telling patients with afternoon cases that they can eat as long as it's 8 hours before.

Yesterday I had a 4pm case and the patient ate at 8am. Because the nurse told them it was fine.

I haven't really dealt with this before because I've been always used to NPO after midnight. I find it silly because I was unable to move this case up into another room, which would have made it so staff didn't have to stay an extra 3 hours.

I also am not a fan of treating every patient the same (diabetic, renal failure, people taking narcotics). We've all done egds on fasted patients with food in their stomachs.

How does everyone else feel about this/What is everyone else's policy?

 

[TheLoneWolf]

Recently I've had more patients eating the day of their elective surgeries. The ASA states an 8 hour NPO prior to procedure time.

Our patients are usually told their arrival time to the surgery center/hospital, and not their surgery start time. However, nurses that call the night before are telling patients with afternoon cases that they can eat as long as it's 8 hours before.

Yesterday I had a 4pm case and the patient ate at 8am. Because the nurse told them it was fine.

I haven't really dealt with this before because I've been always used to NPO after midnight. I find it silly because I was unable to move this case up into another room, which would have made it so staff didn't have to stay an extra 3 hours.

I also am not a fan of treating every patient the same (diabetic, renal failure, people taking narcotics). We've all done egds on fasted patients with food in their stomachs.

How does everyone else feel about this/What is everyone else's policy?

Orthos at ASC have been encouraging their afternoon cases to have a breakfast of toast up to 6 hours prior to their scheduled case time. Problematic when patient rather unconsciously adds butter, jams, or deli meats to that.

Then again, these guys couldn't be bothered to tell their patients to hold their GLPs for a week prior to elective joints. (Back when that was the ASA recommendation)

 

[markneil]

This is why I will never work in an ASC.

 

[aneftp]

Wasn’t the original npo study done on 5 foot 10 150 male med students?

But the real issue is
1. Portion of food consumed. Some people consider a light breakfast an all u can get breakfast buffet

2. Just like telling patients they can consume clears 2 hr besides surgery. Is a 64 bottle of sprite 2 hr before surgery ok?

 

[rowsdower88]

Just like telling patients they can consume clears 2 hr besides surgery. Is a 64 bottle of sprite 2 hr before surgery ok?

Lol. Have you had someone try that?

 

[spike7585]

I'm still wrapping my head around doing an elective case starting at 4pm

They want to eat a breakfast at 8am, then fine, but like you said, it ain't gonna get moved up

And not sure how your example of different patients not being treated the same matters in this scenario. They're 8 hours NPO, the only difference is they didn't sleep during those 8 hours?

If you have a diabetic ESRD patient for a 730am start and they ate dinner at 11pm the night before, are you going to be delaying it or concerned bc of their comorbidities? This is no different for an afternoon start.

 

[aneftp]

Lol. Have you had someone try that?

Yes! Had his wife bring in the bottle of sprite and what was left of it. Not much. Just simple eyeballs at outpatient center. Just puts you in an awkward situation. Push it to last case

 

[cchoukal]

Lol. Have you had someone try that?

definitely. one of my venues previously tried to let patients do clears at 2 hours, and, predictably, people try to push the envelope and take things to the extremes. "Sparkling water, that's clear!" even with its acidic pH. Black Coffee morphing into a giant Latte. Ended up going back to "NPO after MN."

 

[ProRealDoc]

Wasn’t the original npo study done on 5 foot 10 150 male med students?

But the real issue is
1. Portion of food consumed. Some people consider a light breakfast an all u can get breakfast buffet 🤣🤣

2. Just like telling patients they can consume clears 2 hr besides surgery. Is a 64 bottle of sprite 2 hr before surgery ok?

 

[narcusprince]

Any of you utilizing gastric ultrasounds? Seems like this could help the decision making process.

 

[NPJR]

Any of you utilizing gastric ultrasounds? Seems like this could help the decision making process.

How much can you bill extra for it? or is it another freebie?

 

[ambiturner]

Any of you utilizing gastric ultrasounds? Seems like this could help the decision making process.

I could see doing this for big meals where they are now technically NPO, but if you did ultrasound on someone who ate a hamburger 4 hours ago and there was nothing in the stomach, would you start the case? My concern with gastric US has always been that, if that guy aspirates, you’re in big trouble and a negative ultrasound won’t protect you.

 

[NumTacos]

Any of you utilizing gastric ultrasounds? Seems like this could help the decision making process.

I keep hearing people say this. I feel like unless you are credentialed and there is an official pathway/hospital SOP to use POCUS gastric ultrasound, I doubt it would protect against litigation.

 

[pgg]

Any of you utilizing gastric ultrasounds? Seems like this could help the decision making process.

I went to a POCUS workshop put on by my state's ASA chapter a couple months ago. Gastric ultrasound was part of it.

There were a bunch of models that we scanned one morning, then again after lunch. (Naturally all of the models were young healthy medical students with BMIs under 30.) It wasn't a real hard skill to pick up, but .....

I don't do gastric ultrasounds in my daily practice now and I don't think I'll start. If any elective case violates NPO guidelines, it gets canceled. I'm not emotionally or financially vested in those patients getting their surgery done that day.

If an urgent or emergent case isn't NPO, the case gets done and the patient gets a tube. I struggle to conjure a compelling reason to go to the trouble of doing gastric ultrasounds, because the result isn't going to impact my management.

 

[mdo1738]

I went to a POCUS workshop put on by my state's ASA chapter a couple months ago. Gastric ultrasound was part of it.

There were a bunch of models that we scanned one morning, then again after lunch. (Naturally all of the models were young healthy medical students with BMIs under 30.) It wasn't a real hard skill to pick up, but .....

I don't do gastric ultrasounds in my daily practice now and I don't think I'll start. If any elective case violates NPO guidelines, it gets canceled. I'm not emotionally or financially vested in those patients getting their surgery done that day.

If an urgent or emergent case isn't NPO, the case gets done and the patient gets a tube. I struggle to conjure a compelling reason to go to the trouble of doing gastric ultrasounds, because the result isn't going to impact my management.

Exactly. I can’t fathom the thought process that goes into doing extra work to put yourself at higher liability. ASA recs exist for a reason (many reasons).

 

[Maz777]

Gastric U/S is only useful if you think someone is lying about being NPO (i.e. they changed their story during check-in) and you need data to cancel the case. It's a means to cancel. Not a means to reassure yourself and proceed.

 

[Gator7]

Yea I’m not doing gastric ultrasound. If it’s elective follow the guidelines, if it’s emergent then I’m treating as full stomach anyway.

But yes we need to go back to nothing after midnight. Patient’s can barely get that right. I had to spend my morning recently researching where the heck honey falls on the list. Is it clear? Is it syrup? Light meal? Who eats honey for breakfast?

 

[Dantrolene FC]

Somewhat similar question.

What is the threshold of water to call it 2 hours vs ignoring it?

I had a patient who drank a half bottle of water on the way to pre-op. I delayed the case for 2 hours. Would others have delayed the case as well?

 

[coffeebythelake]

Somewhat similar question.

What is the threshold of water to call it 2 hours vs ignoring it?

I had a patient who drank a half bottle of water on the way to pre-op. I delayed the case for 2 hours. Would others have delayed the case as well?

Anything more than sips for taking pills = 2 hour wait.

 

[Gator7]

Anything more than sips for taking pills = 2 hour wait.

Is there any data on the new trend of giving patients water and a bucket of ERAS pills right before wheeling to the OR? I’m gonna lose my mind the first time I see Tylenol in the trachea.

 

[Dantrolene FC]

Is there any data on the new trend of giving patients water and a bucket of ERAS pills right before wheeling to the OR? I’m gonna lose my mind the first time I see Tylenol in the trachea.

You don’t give your patients Tylenol before surgery?

I give Tylenol to anyone having a procedure associated with pain (so basically anyone except cataracts and endo). I’ll give aprepitant to people at risk for nausea.

Some of our surgeons will give gabapentin.

 

[Gator7]

No I’m saying more in terms of NPO status. We say clear liquids is 2 hours but then allow ERAS pills right before they go to sleep.

 

[gunnershow]

No I’m saying more in terms of NPO status. We say clear liquids is 2 hours but then allow ERAS pills right before they go to sleep.

Because water doesn't matter at all. It clears basically immediately. I consider myself strict on NPO guidelines but I've never delayed someone for water.

 

[circleK]

But yes we need to go back to nothing after midnight. Patient’s can barely get that right. I had to spend my morning recently researching where the heck honey falls on the list. Is it clear? Is it syrup? Light meal? Who eats honey for breakfast?

Had a patient who had a protein shake the early morning of his case. He thought it was clear bc he mixed it with water 😑.

 

[GassYous]

Is there any data on the new trend of giving patients water and a bucket of ERAS pills right before wheeling to the OR? I’m gonna lose my mind the first time I see Tylenol in the trachea.

Start giving it colonically

 

[cchoukal]

How about chewing tobacco?

 

[Dantrolene FC]

How about chewing tobacco?

I ignore it. My group is all over the place. Some ignore it, some call it 2 hours, some call it 6 hours.

 

[Guillemot]

I posted this in another thread covering a similar topic:

“
POCUS can solve the equivocation as to whether XXX meal is a light meal requiring six hours of fasting or eight hours. It still allows adherence toASA’s fasting guidelines, which is standard of care. However, we all know the ASA guidelines are somewhat ambiguous and open to interpretation in regard to the “light meal“. I’d say it’s worth the investment in learning it as it can make one’s life a lot easier rather than just winging it and hoping for the best vs unnecessarily, delaying the case

They’re still is the matter of optimizing patients prior to arrival, though and as far as I know, there is not a definitive standard of care for GLP1 agonists in that regard. I think most places heard of have rules of is either hold it 1-2 weeks or clear liquids for 24 hours. As long as the patient had followed those institutional rules, I would proceed forward with the case, but just taylor my anesthetic based on POCUS findings.”

 

[pgg]

How about chewing tobacco?

Unless they're guttin' it, I treat it the same as gum.

 

[Ronin786]

Gastric U/S is only useful if you think someone is lying about being NPO (i.e. they changed their story during check-in) and you need data to cancel the case. It's a means to cancel. Not a means to reassure yourself and proceed.

What if somebody is telling the truth and gastric U/S is indeterminate or shows a full stomach? Call them a liar and cancel?

Because if that's the case we should be ultrasounding everybody and making it standard of care.

 

[Maz777]

What if somebody is telling the truth and gastric U/S is indeterminate or shows a full stomach? Call them a liar and cancel?

Because if that's the case we should be ultrasounding everybody and making it standard of care.

Stories don't change if somebody is telling the truth. "I had a burrito this morning at 6am" when the preop RN first asks turn into "Oh wait, I just had one bite of toast at 4am" once they realize it might affect their 10am surgery.

We should absolutely not be doing gastric U/S on everyone.

 

[PpfSuxTube]

I went to a POCUS workshop put on by my state's ASA chapter a couple months ago. Gastric ultrasound was part of it.

There were a bunch of models that we scanned one morning, then again after lunch. (Naturally all of the models were young healthy medical students with BMIs under 30.) It wasn't a real hard skill to pick up, but .....

I don't do gastric ultrasounds in my daily practice now and I don't think I'll start. If any elective case violates NPO guidelines, it gets canceled. I'm not emotionally or financially vested in those patients getting their surgery done that day.

If an urgent or emergent case isn't NPO, the case gets done and the patient gets a tube. I struggle to conjure a compelling reason to go to the trouble of doing gastric ultrasounds, because the result isn't going to impact my management.

100%. Gastric uss makes absolutely no sense. If its elective and they've violated npo status thats their issue. If its not elective then its an rsi tube.

Why role does gastric uss have other than to be pushed to do cases you'll regret?

 

[Dantrolene FC]

100%. Gastric uss makes absolutely no sense. If its elective and they've violated npo status thats their issue. If its not elective then its an rsi tube.

Why role does gastric uss have other than to be pushed to do cases you'll regret?

The only time I’d do gastric ultrasound would be if someone has significant cardiac disease but is only like 5 hours fasted, then I could use it to determine if I want to do an RSI or a standard induction. But then, even at that, I’d probably skip it and just do a standard induction.

 

[NumTacos]

The only time I’d do gastric ultrasound would be if someone has significant cardiac disease but is only like 5 hours fasted, then I could use it to determine if I want to do an RSI or a standard induction. But then, even at that, I’d probably skip it and just do a standard induction.

So what you are saying is you’ll just do the same exact thing you would’ve done already, gastric ultrasound, or not?

 

[Dantrolene FC]

So what you are saying is you’ll just do the same exact thing you would’ve done already, gastric ultrasound, or not?

I was giving a scenario that POCUS could be useful, but then said it’s not really necessary.

 

[NumTacos]

I was giving a scenario that POCUS could be useful, but then said it’s not really necessary.

 

[psychbender]

I had a patient on both tirzepatide (for weight loss) and semaglutide (for heart failure). She stopped one, but not the other, and couldn't remember which, but was appropriately fasted. First case of the day no-showed, OR wasn't ready for second case (her case), so I wheeled the USD over and made her move all around. Got great images of a totally empty stomach, so we went ahead with her planned cysto.

For what is worth, I also teach at POCUS courses, so I was confident in the images I obtained. I would not recommend a novice do the same, and think gastric ultrasound is neat, but really doesn't have a good place in our work flow.

 

[cittykat]

I had a patient on both tirzepatide (for weight loss) and semaglutide (for heart failure). She stopped one, but not the other, and couldn't remember which, but was appropriately fasted. First case of the day no-showed, OR wasn't ready for second case (her case), so I wheeled the USD over and made her move all around. Got great images of a totally empty stomach, so we went ahead with her planned cysto.

For what is worth, I also teach at POCUS courses, so I was confident in the images I obtained. I would not recommend a novice do the same, and think gastric ultrasound is neat, but really doesn't have a good place in our work flow.

Finding a full stomach would have made the decision even easier.