NPO before surgery is nonsense

GadgetRN71, ASN, RN · Jan 27, 2009

If a patient has anything in their stomach, water food etc when the anesthesia provider goes to intubate, the patient may aspirate. I've seen it happen, and the outcome for the patient isn't good. The rules for clear liquids are slightly different but I know many anesthesiologists that are stringent with these rules. I think they should be...it may seem like overkill, but better safe than sorry.

In my hospital, if you have something to eat or drink before your surgery when you're not supposed to, surgery is canceled. Unless, of course, it's a dire emergency or trauma.

And obviously, we CAN'T trust patients or nurses to follow the guidelines...plenty of patients are still getting fed when they're not supposed to. I would think "nothing to eat or drink after midnight" is pretty dang straightfoward, but apparently not. :no:

shodobe · Jan 27, 2009

Over the years I have had so many different anesthesiologists have so many opinions on NPO status it would make your head spin. It now has gotten to the point where most , if not all just want their patients NPO for a few hours on clear liquids but up to 8 hours if they have had solid foods. Children under a certain age, especially infants only a few hours if they have had clear fluids, but not milk. If it is an emergency then the whole NPO thing goes out the window. We do have a chart we follow but I can't think of all the parameters right now. But as I said, water is pretty much OK if not taken in large quantities. We do try to use the 8 hours if at all possible but it isn't really adhered to anymore. We cancel more surgeries due to lab results, bad x-rays , bad patient or ? than NPO status. I have more patients throwup that were supposed to be NPO than those I knew had had some water just a few hours prior.

$fracturenurse$ · Jan 27, 2009

Like the previous post, aspiration is the major deal...Anesthesia providers don't even want to touch that one!!!!! I saw it happen the other day, lady started vomiting after induction, we suctioned...yada yada yada, the anesthesiologist got the bronchoscope, looked in the lungs and yes, she aspirated....UGH!!!

It's not that we don't trust patients or nurses, but the general public just have no idea what surgery involves. They have no idea how dangerous anesthesia can be. Ask any nurse on this forum and they will tell you about an experience they have had with a patient that "lied" and said they didn't eat anything and we end up suctioning all sorts of crap out of their stomach.

There are things we can do to help prevent aspiration, but please just keep the patient NPO, it's better to be safe than sorry!!!:wink2:

Pediatric Critical Care Columnist · Jan 27, 2009

What I can't wrap my head around is that patients in our unit are, in the vast majority, fed nasojejunally so in theory they should not be able to vomit anything but gastric secretions. But we put them NPO at midnight for surgery "sometime" tomorrow, or at 0400 for extubation "in the morning" which typically means more like mid-afternoon. It's a bit of a conundrum to me.

Editorial Team / Admin · Jan 27, 2009

Most of the anesthesiologists I work with say 6-8 hours for solid food, and 2 hours for clear liquids. The only exception seems to be oral contrast for CT, but that typically happens in the more urgent cases. We also don't operate on kids under 12 mos after 5pm, so there isn't really an issue with infants. Not sure how it works for the scheduled cases, I'm pretty much trauma/emergent.

ewattsjt · Jan 27, 2009

i think it is both not trusting patients, old habits, and lump everyone into one group so nothing gets confused. standard order for my facility is npo after midnight but in cases where the patient does ingest food, they fall back to six hours.

i have seen where patients come in and did their npo. they didn’t have any meals but this morning they only ate one bacon strip, half a biscuit, and half a cup of coffee. wasn’t a meal so they were good to go. lol had one patient from the floor who thought the npo wasn’t a big deal and wanted to get their energy up for the surgery and had half a cheese burger before coming to surgery. if patients easily confuse npo with just a little bite of something then how do they react if you say it is ok to have water? it simply adds to their misconception of not being a big deal.

the latest data reflects that 6 hr npo is sufficient in most cases. it is however easier and less confusing to everyone to lump everyone into the same group rather than saying that for this person it is 6 hr npo while this one is 8 and this one is 9 and this person can have ice chips or water while this one shouldn’t.

the data also reflects that water up to two hours prior to surgery has no effect in most cases.

one last thing in my opinion is why would a doctor risk a patient aspirating as well as a malpractice suit for the patients who fall outside this norm? especially when it is proven that npo after midnight works well and has been a standard for years. keep in mind that both the surgeon and anesthesiologist can cancel the case if the patient went outside their npo guideline. maybe the anesthesiologist agrees with 6hr but the surgeon doesn’t.

here is a related link

http://www.ncbi.nlm.nih.gov/pubmed/10172278

morte, LPN, LVN · Jan 27, 2009

i would like to see the Brits on the board chime in on this one.....i was under the impression that in the UK this rule had gone the way of the dodo bird.....

Guest219794 · Jan 27, 2009

I have been told that studies in GB indicate that PO hydration has a benficial effect.

hherrn

hypocaffeinemia, BSN, RN · Jan 27, 2009

janfrn said:
What I can't wrap my head around is that patients in our unit are, in the vast majority, fed nasojejunally so in theory they should not be able to vomit anything but gastric secretions. But we put them NPO at midnight for surgery "sometime" tomorrow, or at 0400 for extubation "in the morning" which typically means more like mid-afternoon. It's a bit of a conundrum to me.

My best guess is that, although the upper GI tract is avoided in your feeding route, large aspects of the GI tract work in concert with each other-- the stimulus in the jejunum probably increases gastric secretions, the same way chewing gum increases gastric secretions. GI secretions can be as high as 1-2L per 24 hours.

Pediatric Critical Care Columnist · Jan 27, 2009

hypocaffeinemia said:
My best guess is that, although the upper GI tract is avoided in your feeding route, large aspects of the GI tract work in concert with each other-- the stimulus in the jejunum probably increases gastric secretions, the same way chewing gum increases gastric secretions. GI secretions can be as high as 1-2L per 24 hours.

That would be a LOT of gastric secretions in a 3 kg infant... But point taken.

*ac* · Jan 27, 2009

Is chewing gum OK when NPO? Is sweeties (the stuff we dip the pacifier in for babies)?