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abcxyz0123

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just curious. I had a septoplasty done last week, and inadverdently drank about 1/4 of an old water bottle in my car on my way to the surgery center (i realized my mistake by the time I got to the surgery center). the anesthesiologist laughed at me, and then told me they would have to start the surgery 1 hour later to let the water pass.

they told me not to drink water for at least 6 hours prior to surgery. why was it ok that I was able to drink water 2 hours prior? and what exactly would have happened if I didnt tell the anesthesiologist the truth. do people die from this?
 

CookWithGas

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its the whole idea of avoiding the full stomach and thereby avoiding the risk of aspiration. as far as i know when someone just drinks clear liquids there is not much that needs to be done with regards to digestion and therefore it will definitely (in most cases) be emptied by the two hour mark...but once you start adding things like fruit, food, or thickened liquid substances these things stay around a bit longer and therefore increase the risk of having a "full" stomach.

to the question of "do people die from this" I'll leave that to a resident to answer...but Im sure people do die from aspiration...but whether the the 1/4 cup of poland spring you drank is the source of reportable deaths...that's another question.
 

Bertelman

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just curious. I had a septoplasty done last week, and inadverdently drank about 1/4 of an old water bottle in my car on my way to the surgery center (i realized my mistake by the time I got to the surgery center). the anesthesiologist laughed at me, and then told me they would have to start the surgery 1 hour later to let the water pass.

they told me not to drink water for at least 6 hours prior to surgery. why was it ok that I was able to drink water 2 hours prior? and what exactly would have happened if I didnt tell the anesthesiologist the truth. do people die from this?

Why can't you drink water? The muscles keeping your stomach contents in your stomach relax, then the contents can travel up to your throat and into your lungs. That's bad.

It was OK to just wait only 2 hours because the volume of water you drank was relatively small. If you had consumed an entire bottle, or weren't a young, healthy patient, they would have made you wait the full 6 hours.

If you had lied, there is a small chance the water and acid in your stomach would have traveled to your lungs. You may have been hospitalized longer. Yes, some people can die from this, but they tend to be older, less healthy people.
 
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invitro

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CA-1 anesthesia resident here.

NPO guidelines are the follows:
OK 2hrs before sx : clear liquids
OK 4hrs before: Breast milk
OK 6hr before: non human milk, light solid food
OK 8hr before: anything

I guess if you did not tell the anesthesiologist there may be a chance that you could aspirate something, but since you appear to be relatively young, an asp pna shouldn't kill you. In an old decompensated person it can be serious. There were so many old men/women suffering from aspiration pna in the micu where I worked as an intern....the mortality rate was quite substantial.

Maybe the attgs will chime in if I said anything wrong...
 

IceDoc

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CA-1 anesthesia resident here.

NPO guidelines are the follows:
OK 2hrs before sx : clear liquids
OK 4hrs before: Breast milk
OK 6hr before: non human milk, light solid food
OK 8hr before: anything

Maybe the attgs will chime in if I said anything wrong...

And just to be clear, there is a lot of voodoo behind the npo guidelines. For example, we still make obstetric patients follow these guidelines, but they're still basically full stomachs at the 8 hour mark. Also, I can tell that if I stuff myself the night before, I'll still have food in my stomach 10hours later. So what's the point of the guidelines?

Anyway, what makes an aspiration bad is acidity, not necessarily volume. So the volume of the water itself wasn't all that bad. However, if your stomach started churning out acid because it thought it was going to get a nice breakfast, than you'd be at increased risk IF you aspirated (which is still a rare event).

Voodoo? Yes. But I still follow the guidelines.
 
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tussionex

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um, also, does anyone find that drinking old water that one finds in the car kind of gross?:rolleyes:
 
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Idiopathic

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Actually, weve been taught that its both acidity AND volume that matter. But in reality, particulate matter is probably the worst.

And Art Wallace mentioned at our grand rounds the other day that the reasonable estimate is that 1/20,000 "full stomachs" will actually aspirate and see morbidity from it. (exclusing obstetrics)
 

Dejavu

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I thought all that stuff about NPO is based on a pretty weak study back a long time ago. The validity of pH 2.5 and gastric volume isn't well supported IIRC.

As part of the Total Joint Pain Protocol we have (many peripheral nerve blocks and Bupiv drips and po narcs postop), we give Oxycontin, Neurontin and Celebrex orally to many many pts a day just as they head to the OR. No aspiration problems in several years of doing this.

I have further expanded that and give this "cocktail" to any of my pts that are going to be undergoing major surgery and may wake up hurting.

I should add that we follow ASA NPO guidelines otherwise...go figure
 

Laurel123

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Two months ago we had a healthy 24 year old come in with a ruptured appendix. He was in pretty bad pain and they had to proceed urgently. He had a rapid sequence induction with cricoid, and after all the induction agents were pushed, he vomited some particulate matter and aspirated. He was kept on mechanical ventilation with PEEP post-op and by day 2 he had full blown ARDS and by post-op day 3 he had died.

Now, unfortunately, I don't have too many of the details because it was just presented at the chart review, and I was post call. But I do know that the patient was healthy previously, the surgery was emergent, and upon peer review it was found that appropriate care was given.

I was just sharing that healthy young people can die from aspiration. However, while this person was previously healthy - he had an acute abdomen and was having a lot of pain, had some IV opiates so he had significant risk factors for aspiration.
 

Idiopathic

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Have also seen this happen with an elective lap sigmoidectomy in a healthy <40 y.o. Extubated, required reintubation, vomited with aspiration on reintubation, ARDS, code, coma, death.
 

SleepIsGood

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just curious. I had a septoplasty done last week, and inadverdently drank about 1/4 of an old water bottle in my car on my way to the surgery center (i realized my mistake by the time I got to the surgery center). the anesthesiologist laughed at me, and then told me they would have to start the surgery 1 hour later to let the water pass.

they told me not to drink water for at least 6 hours prior to surgery. why was it ok that I was able to drink water 2 hours prior? and what exactly would have happened if I didnt tell the anesthesiologist the truth. do people die from this?

Not sure if you are in medicine or not. Regardless, I think you really shouldn't hold anything back from your doctor. Not just for surgery but for almost anything in medicine doctors take what you say as the truth. There are things we would do differently if we hear certain things. So I would always say the truth. This goes for drug abuse,etc. Serious complications CAN arise if we are not informed ahead of time of what we should expect.:thumbup:
 

coprolalia

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What about Jello? Is that a clear liquid?

Had a huge argument with an attending about this one recently. This obese 13 y.o. kid was hungry and complaining because she had to wait to go for surgery (unexpectedly prolonged case before hers). The scheduler told the nurse to give her some Jello. I took her into the OR, found out that she'd eaten Jello about 3 hours beforehand. I called the scheduler (who is an anesthesiologist) from the OR with the patient still on the Gurney and he said it was okay, go ahead and start the case. I told him that I didn't think Jello, although you often here it stated, is considered a "clear liquid" and that we should at least delay until four hours. He basically told me that I was the resident (i.e., *****) and that if I delayed the case, he'd write us up for the delay (how's that for getting your back?). Me and my attending were pissed, although this particular attending is so spineless that he didn't want get in the middle of it (can you believe that?).

I gave her Reglan, we started the case, intubation went fine. Nearing the end of the case, just for sh*ts and giggles, I dropped an OG tube down the patient. Guess what happened? I sucked out about 200mL of a orangy, frothy gelatinous substance that looked suspiciously like Jello.

I think what pissed me off the most was that the scheduler was in no other way connected to the case. His name never appeared anywhere as authorizing the Jello. And, knowing this schmo, if something HAD happened (i.e., aspiration), then he sure as hell wouldn't have stepped up and taken responsibility. Hell, I'm positive he never even went and saw the kid but just authorized it on the phone.

Now, we can debate the pH of Jello and whether or not it would've damaged the lungs, but in my book it's better not to conduct such experiments on children, at least without IRB approval. Next time, I cancel the case and/or we wait a full six hours.

-copro
 
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chimichanga

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The scheduler must have had some (bad mojo) contact w/ a militant CRNA...

Damn murses...Their incompetence infects the profession...
 

epidural man

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And just to be clear, there is a lot of voodoo behind the npo guidelines. For example, we still make obstetric patients follow these guidelines, but they're still basically full stomachs at the 8 hour mark. Also, I can tell that if I stuff myself the night before, I'll still have food in my stomach 10hours later. So what's the point of the guidelines?

Anyway, what makes an aspiration bad is acidity, not necessarily volume. So the volume of the water itself wasn't all that bad. However, if your stomach started churning out acid because it thought it was going to get a nice breakfast, than you'd be at increased risk IF you aspirated (which is still a rare event).

Voodoo? Yes. But I still follow the guidelines.

Obstetric patients are considered full stomach not because of food that might be in the stomach, there are many physiologic reasons they are considered full stomach. I think if a pregnant person ate, here stomache would empty just like yours or mine will. When I stuff myself a night before, I am more hungry in the morning - I think something is wrong with your stomach.

As mentioned, both acidity and volume are important, and also I don't think that the guidelines are based on vodoo, but on the best evidence that we have based on gastric emptying studies.

Interestingly, there is some good stuff that shows drinking water right before surgery actually helps empty the stomache quicker.

One thing I never understood is why we consider obesity as a risk factor for full stomache. They CLEARLY empty their stomachs well, and fast, since they are always hungry. (I think their pH is much lower - so I'll give you that.)
 

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The scheduler must have had some (bad mojo) contact w/ a militant CRNA...

Damn murses...Their incompetence infects the profession...

I dont get what you are saying. Wouldnt the anesthesiologist scheduler be the incompetent one? Also the attending in the room supervising the resident. Who cares what the scheduler thinks. The one who is responsible is the attending in the room.
 

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just curious. I had a septoplasty done last week, and inadverdently drank about 1/4 of an old water bottle in my car on my way to the surgery center (i realized my mistake by the time I got to the surgery center). the anesthesiologist laughed at me, and then told me they would have to start the surgery 1 hour later to let the water pass.

they told me not to drink water for at least 6 hours prior to surgery. why was it ok that I was able to drink water 2 hours prior? and what exactly would have happened if I didnt tell the anesthesiologist the truth. do people die from this?

Yes you can die sadly. You can thow up and and choke on your own vomit Thats what my doctor told me
 

Ronin786

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Speaking of NPO guidelines, does the volume of clear liquids within two hours matter? ASA guidelines only specific clear liquids without a specific volume.
 

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I heard of a death on induction due to aspiration a few weeks ago, patient had some sort of intra-abdominal cancer, SBO due to mass effect. I have no more additional details other than the patient aspirated, desated, was coded, and pronounced in the OR. There are many situations where "guidelines" may not describe the exact clinical scenario you find yourself in, but there are real reasons to take aspiration seriously and use the available

In my own personal experience (I am a CA-2), twice I have had patients vomit during emergence/extubation and in both situations, I took over the case and it was signed out that the patient had been NPO for greater than 12 hours. Both were young and healthy, one male with a motorcycle de-gloving injury to his hand, the other a 20-something female having a lap appy. Both vomited serious chunks, I could describe exactly what he had ordered in his omelette and I knew that she really liked corn. Both patients had received multiple agents for PONV prophylaxis. Fortunately, they both did okay and their hospital courses were not prolonged due to aspiration.
 

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in both situations, I took over the case and it was signed out that the patient had been NPO for greater than 12 hours. Both were young and healthy, one male with a motorcycle de-gloving injury to his hand, the other a 20-something female having a lap appy.

Are you saying that you were reassured by the fact that these two patients had been NPO x 12 hours? And you were surprised they had residual gastric contents?
 

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What was the interval between the meal and the traumatic incident. That's the most important question to ask. Not the npo duration from time of trauma
 
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