How long is it reasonable to leave someone NPO for?

[Archana Shrestha, BSN, RN]

It is a very good question. The facility where I am currently working have the Protocol of providing Supplement/ replacement fluids if the patient is kept NPO. Also, frequent assessment is done for signs of fluid overload like lungs auscultation, Monitor for peripheral edema, weight gain e.t.c

The thing is, patients are kept NPO (Nothing per Oral) for various reasons, which could be due to certain progressive disease conditions or may be due to surgical procedures (Operations) or for short procedures like Ultrasound of the Abdomen and Pelvis, CT scan, Endoscopy e.t.c. 

The duration for keeping the patient NPO could differ.

1. Talking about surgical procedures, NPO is ordered for the prevention of aspiration pneumonia, e.g., in those who will undergo general anesthesia. After most of the major operations, patients are kept NPO for 4 hrs to 6 hrs, May prolong to 10 hrs -12 hrs (According to the hospital protocols), and In cases of abdominal surgery, NPO is ordered for up to 12 hrs to 72 hrs. Even though patients are kept NPO, those post-operative patients are given fluid replacements/ Supplements (Dextrose, Normal Saline, lactate ringers, TPN) as per requirements ordered by a doctor.

2. Although the scenarios in which patients are kept NPO due to their disease progression are different. Some common conditions where patients are kept NPO are those with weak swallowing musculature or, in case of gastrointestinal bleeding, gastrointestinal blockage, or acute pancreatitis, Severe vomiting. Whatever the above-mentioned condition might be, there is always the order of fluid replacement/ supplement, just like I've mentioned above in surgical causes. 

3. Lastly, about the small procedures like CT Scan, USG of the abdomen and pelvis, and Endoscopy, the order for NPO is for a short duration, maybe after midnight or prior to 4hrs to 6hrs before procedures. In such conditions, normally, IV fluids are not prescribed.

Hope this information helps.

[Crux1024]

The evidence I can't help you with.

Around my parts, at three days, something needs/begins to be done. And that's 2x too long.

It'd be interesting to see if there is any evidence-based practice for this. Good Question.

[denice142]

I have a patient that has been NPO for a week. She is confused and has failed two swallow studies. The family refused for her to have a peg tube placed but agreed to a PICC for TPN. However, when the PICC nurse came, she refused. There was a big debate over whether or not she was competent to refuse, but she hadn't had anything to eat for a week. Tonight she wanted a banana, which I could not give her, of course, but I did give her thickened liquids. She did okay with them but is still complaining she is hungry. It's a thin line we walk in comforting our patients and doing what is best for them (I.e., being NPO).

[Flo., BSN, RN]

Three days then they get the attention of the RD. 

[RNKPCE]

I had a family member that had surgery on Tuesday and had a small amount of a few clear liquids, meals, and a few bites of solids before he got an ileus and was made NPO on Friday and was NPO until the following Tuesday. He had IV fluids the whole time. One person on the medical team said they don't consider TPN until day ten, but another doc was talking about TPN on the 6th day after a procedure. The ileus resolved, and he could eat day starting with clear liquids on day 7.

[NickiLaughs, ADN, BSN, RN]

Kooky Korky said:

Dumb question - if she can handle thickened liquids, couldn't she handle a banana?

I think it depends on the facility's protocol. I know we are allowed to give thickened liquids in very small amounts to see how they do if they haven't been cleared with a swallow eval. But no solids (like bananas) are allowed. I had one patient who was waiting on a swallow eval for two days and was hungry. The Speech Therapist was taking their sweet time, so I kept giving thickened liquids because it was allowed. I would not give her anything else, though, because I didn't want to be the one responsible for her choking on something/aspirating, and then intubating when we were trying to get her out of ICU.

[canesdukegirl, BSN, RN]

OP-very good question indeed. I work in the OR, and this has been a concern of mine when we have had to delay a scheduled afternoon surgery for an emergency case. If I am dealing with a pediatric patient and have to delay their surgery for an e-case, then I will ask the attending to simply reschedule the surgery so that the poor kid can eat already. However, your question seems to be unrelated to a surgical consideration, and I don't want to take it away from your thread.

I will look up and ask my fellow co-workers. I don't know the answer, but I should. I work with a wonderful GI doc that will probably have an answer. I will email him now and ask for some evidence-based articles. I will forward it to you in a PM.

[savvy-nurse]

blondy2061h said:

How long is it reasonable to leave someone NPO with just IV fluids, no TPN or enteral feeds? I'd been searching, and I had a hard time finding evidence to answer this question.

A study was done on surgical patients in the ICU that showed that a 24-hour delay in patient feeding actually adversely affects their condition. These patients tend to stay longer in the hospital and have a higher mortality rate post-discharge. But ICU patients are a special population; the patients have compromised systems and sometimes multiple co-morbidities.

The general rule of thumb is to feed the patient ASAP. Food nourishes the body and promotes healing. Although TF is preferable to TPN, some food is better than none.

Think of your elderly patient who comes in already dehydrated. One more day of no food or fluids is unacceptable if it can be helped.

Unless it absolutely cannot be helped, start talking to your doctor about putting down an NGT temporarily. We are such a stickler for this in the ICU. I think that is a model that will serve patients well if all units adopt it.

[indigonurse]

You can provide adequate fluid and electrolytes via IV, but the nutritional needs for protein are ongoing and get depleted gradually over time. Three days are the rule of thumb that I have always used. Then the person needs to be evaluated for the ability to tolerate PO foods. If not, then TPN vs. G Tube.

[blondy2061h, MSN, RN]

Quote

Since you mention the IVF/TPN/enteral feeds, are you meaning from a nutritional standpoint? Hopefully, they'd only be NPO as long as their condition warranted. But as one NP said to a point, he was admitting at ~02:00, "Here in the South, we feel like we're starving if we don't eat every 6hrs."

I'm referring to it from a nutritional point of view. When do you start seeing negative medical consequences? What is the general rule for when it becomes a poor practice to have a patient with no nutritional source? I think anyone who is NPO is miserable thinking they want to eat even if 2 minutes ago they were barfing their brains out.

[blondy2061h, MSN, RN]

canesdukegirl said:

OP-very good question indeed. I work in the OR, and this has been a concern of mine when we have had to delay a scheduled afternoon surgery for an emergency case. If I am dealing with a pediatric patient and have to delay their surgery for an e-case, then I will ask the attending to simply reschedule the surgery so that the poor kid can eat already. However, your question seems to be unrelated to a surgical consideration, and I don't want to take it away from your thread.
I will look up and ask my fellow co-workers. I don't know the answer, but I should. I work with a wonderful GI doc that will probably have an answer. I will email him now and ask for some evidence-based articles. I will forward it to you in a PM.

Thanks. I was thinking away from surgical cases, since those are usually after midnight, but it is relevant as well. I was thinking more about patients with SBOs and such who it's a few days for before they can have surgery.

I very much appreciate you asking the GI. Thank you!