NPO except for medications

Published

Hello all.

I wanted to get some insight on how much fluid this entails. If the patient is going for a procedure or surgery, but has an order for NPO except for medications, how much fluid do you give if they have 8-10 tabs of medications to take (60ml, 90ml 100ml?). Do you know of a safe range?  What about crushed meds in applesauce if the pt is on a dysphagia diet. I want to make sure it's a safe amount for the patient. I just want an estimation on what you would give. I know calling the doctor is an answer but the reality is calling every day just is not feasible. Thank you. 

Specializes in oncology.
delrionurse said:

I wanted to get some insight on how much fluid this entails. If the patient is going for a procedure or surgery, but has an order for NPO except for medications, how much fluid do you give if they have 8-10 tabs of medications to take (60ml, 90ml 100ml?). Do you know of a safe range?  What about crushed meds in applesauce if the pt is on a dysphagia diet. I want to make sure it's a safe amount for the patient.

I truly am glad you asked this. I reacted for at least these comments. One was this response:

kbrn2002 said:

A little applesauce is also OK for those that require crushed meds

 NOT!   It scared me that at least 2 other people agreed with this advice. 

delrionurse said:

Then the order needs to specify "meds need to be given ONLY with sips of water, otherwise NO MEDS!" These EHR'S and slips in doctor responsibility is getting too much.

I truly advocate that nurses use critical thinking when even dealing with mundane actions. A nurse needs to think about what is planned for the patient's day and what their role is...even a couple hours before then. 

Children's surgeries are scheduled usually first thing in the morning so they are not frustrated by not getting their bottle, juice/breakfast in the morning. Heck even keeping my cat NPO before a surgery stressed me (and her) out. 

delrionurse said:

You have poor examples. 

Yes, my examples above were poor. But I have seen each of these actions done with the exception of blocking a trach. However I have heard of someone who put a plastic bag over a patient's head (the patient did NOT have a trach) to keep scalp sutures dry. She did however poke a hole in the plastic bag so the patient could breathe via nose and mouth. The patient became very anxious and fainted in the shower. 

Up Vote Up Vote ×
Specializes in Tele, ICU, Staff Development.
mtmkjr said:

Think about the rationale for the orders, which is due to relaxation of the esophagus, intubation and potential for nausea later risk of aspiration.

Water, unlike other foods and non-clear drinks being aspirated is not going to cause pneumonia. 

Think also about the fact that just swallowing saliva and the production of stomach acid continues I think around 2 ml per minute enters the the stomach. So whatever it takes within reason should be OK. 

There is a lot of evidence that drinking clear liquids is not harmful 2 hours prior to surgery. In fact being hydrated and having a source of carbohydrate leads to better outcomes (ERAS/Gatorade). This has not changed the practice of ordering NPO after midnight even for surgery scheduled in the afternoon. Maybe someday the orders will become more aligned with evidence. 

I would not give crushed meds and applesauce as that is introducing food. And that is a no go. 

Yes, hospitals are way behind the guidelines. It's better for patients to go into surgery hydrated and with some sustenance.

 

2
Up Vote Up Vote ×
Specializes in oncology.
Nurse Beth said:

This has not changed the practice of ordering NPO after midnight even for surgery scheduled in the afternoon.

With surgery not scheduled in the morning....scheduled late afternoon, our anesthesiologists say they can have a clear liquids until 6 hours before surgery. There is a plethora of research done in this area on stomach emptying times of liquids. 

Nurse Beth said:

Yes, hospitals are way behind the guidelines. It's better for patients to go into surgery hydrated and with some sustenance.

can you point me to the way to find the guidelines?

1
Up Vote Up Vote ×
Specializes in Tele, ICU, Staff Development.
londonflo said:

With surgery not scheduled in the morning....scheduled late afternoon, our anesthesiologists say they can have a clear liquids until 6 hours before surgery. There is a plethora of research done in this area on stomach emptying times of liquids. 

can you point me to the way to find the guidelines?

The American Association of Anesthesiologists practice guidelines way back from 2010, I believe.

The couple of times I've had surgery- I have my coffee, despite what the office tells me.

1
Up Vote Up Vote ×
Specializes in oncology.
Nurse Beth said:

The couple of times I've had surgery- I have my coffee, despite what the office tells me.

You are saying you have such poor impulse control, that you did not want to cooperate with the Medical plan of care?

Up Vote Up Vote ×
Specializes in Tele, ICU, Staff Development.
londonflo said:

You are saying you have such poor impulse control, that you did not want to cooperated with the Medical plan of care?

I followed the evidence.

Up Vote Up Vote ×
Specializes in oncology.
Nurse Beth said:

I followed the evidence.

 

Curious...what did you say to the Pre-An nurse when the question was asked when you last drank, or ate anything?

Here are more current studies: 

The good, the bad, and the ugly of evidence-based practice - PubMed (nih.gov)

Evidence-Based Medicine: Common Misconceptions, Barriers, and Practical Solutions | AAFP

 Your citation is from 2010..but you did not show the plethora of evidence you think there is. I respect you and your column but I believe you are steering pre-op nurses on the wrong course. If Coffee is okay, how about cream in coffee, how about a second cup? A little oatmeal if I  need to thin it down with milk? Applesauce etc.

If that cup of coffee is so vital for you for a 0600 or 0700 surgery, you need to rethink your "needs" for things. 

 

Up Vote Up Vote ×
londonflo said:

[...]

Your citation is from 2010..but you did not show the plethora of evidence you think there is. ...

[...]

Did you read the link I provided?  It was from 2017. 

The Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration, available on Guideline Central and updated 14 March 2022, allow the following:

  • Clear liquids >2 hours
  • Breast milk >4 hours
  • Light meal or non-breast milk > 6 hours
  • Fried or fatty foods >8 hours

The full text link on the Guideline Central site links to the 2017 article I provided above.

3
Up Vote Up Vote ×
londonflo said:

You are saying you have such poor impulse control, that you did not want to cooperate with the Medical plan of care?

I agree with @Nurse Beth's response to this post.  Depending on the scheduled OR time it's not necessarily poor impulse control.  

For my recent surgery I was ordered strict NPO at 2400 for a 0800 report time.

2
Up Vote Up Vote ×
Specializes in Med-Surg.

Our anesthesia department follows the 6-hour rule if a patient has eaten and had fluids.  But for the most part they are NPO after midnight.  Many people though have had emergent surgeries and they seem to do okay from my experience.  

Back to the op I don't give the patient a whole lot of fluids to take important meds pre-op and I tell them "drink as little as possible to get the pills down".  99% percent of the time it's not a problem.  But it is a good question "well how much is too much".  

Up Vote Up Vote ×
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Nurse Beth said:

The American Association of Anesthesiologists practice guidelines way back from 2010, I believe.

The couple of times I've had surgery- I have my coffee, despite what the office tells me.

I have done this in the past as well. I skip the usual cream and sugar and cut the liquid volume to 25% or thereabouts. 

1
Up Vote Up Vote ×
+ Join the Discussion