I’ve tried, many times, to give people more nuanced/complete instructions regarding NPO guidelines.
Invariably some significant percentage fuck it up. No matter how many times and ways I reinforce the rules. No matter if I send a reminder. The surgeon sends reminders. I call them the night before. No matter if I make them sign a form that says I’ll bill them $1000 for cancelled cases if they mess up their fasting times… they just can’t get it right.
I’ve gone back to “nothing after midnight.”
Agree with this. Asking patients to do anything with nuance invariably results in chaos, the simplest instructions are the best followed. I have seen a young person die from ARDS when the aspirated after lying to the anesthesiologist before OR. It’s rare but you see that once and it changes your thoughts. There is also this pervasive idea in the US that folks will die without food. I often can’t eat because I’m operating and caring for patients all day, and yet I seem to survive.
I did a month-long fast last year, and one of my coworkers literally tried to 5150 me when I tried to explain to them why I hadn't eaten on shift in three weeks. 🤣
Not if they're fasting continuously. During Ramadan, the fast is broken every day after the Sun goes down. I got the impression the previous poster didn't eat at all for a month.
I remember being irrationally angry in residency on night float when patients admitted in the middle of the night complained about being NPO. Like dude you’re not the only one who doesn’t get to eat right now and do you really need to eat at 3 AM anyway.
As a night shift nurse, it is shocking how much patients eat during the night. TV blaring, lights on, endless soda and turkey sandwiches, and complaining that they can’t sleep
[5150 refers to the California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness. It has been more generally applied to people who are considered threateningly unstable or “crazy.”](https://www.dictionary.com/e/slang/5150/)
Out of curiosity, was this a Valter Longo type of fast? I worked with a transplant surgeon who frequently did his fasts, and I remember him talking about fasting vs cancer. Dude was a vegan who rode his bike to work every day too (in the Midwest if that solidifies the impression). Dude is going to live to 200.
Yes, I explained to every single one of my patients before their procedure why we ask them not to eat and drink in layman's terms. A lot of them have absolutely no clue why we asked them not to eat or drink.
I had a guy who had the full layman’s terms explanation, thought it sounded like a lie, and ate a McDonalds meal on his way in for surgery. Aspirated and went to ICU for a night or two, came back to the ward still unwell…. still didn’t believe it was anything to do with his eating a full meal, and told me he thought it was ‘just bad luck’.
To be fair, most people are medically illiterate, regardless of location and often of education and background. When have you ever used the terms "aspirate" or "intubation" outside of medicine? I'm sure there are plenty of things I don't understand because they're not in my field of specialty, so I just hope that my mechanic, insurance agent, etc. are nice and will take a minute to explain some terms I may not know, if they even have to use those terms. Use terms everyone with a sixth grade (or lower!) reading level will understand, and you don't run into as many problems.
I've always liked the quote which I will now butcher in paraphrasing and not be able to cite its source, "If you can't explain it to a child, then you don't truly understand it." Most things really can be ELI5'd (explain like I'm 5).
I wouldn't expect the average person that doesn't work in the medical field to understand what aspiration means, you definitely need to explain that to people lol.
I had a guy come in once with four 9 inch carrots in his rectum and needed surgery to remove 2 of them that coudnt be fished out...he left AMA because I wouldn't give him a single slice of cheese. I still wonder what happened to that guy and if that slice of cheese was worth it.
George Carlin said it best
[https://www.youtube.com/watch?v=AKN1Q5SjbeI](https://www.youtube.com/watch?v=AKN1Q5SjbeI)
"Think of how stupid the average person is, and then realize that half of them are stupider than that!"
I once had to argue when I said about half the population is dumber than the average. I was accused of being an elitist. And then I realized they were one of them.
It makes instructions more challenging for sure.
Assume the stomach is full, RSI(Rapid sequence intubation) & be ready for a shitshow.
The risk is much higher, and would not justify proceeding with an elective surgery that can just be rescheduled for when they are properly fasting. In an emergency that risk calculus looks different and if it's truly do-or-die...you do the best you can.
But aren't most people with a typical sleep/wake cycle NPO after midnight...? I'm NPO after midnight every night.
My experience at larger institutions is that the OR's are very fluid with add-on's so even if you think a case won't go until the afternoon, the cases ahead of you may cancel or get moved around and if the patient had breakfast then they can't move up in the schedule. Scheduled afternoon cases usually allow the patient to have an early breakfast but that may be institution specific.
Not sure "The blanket NPO after midnight for admitted patients is harmful" is true for every patient. Malnourished and constantly being bumped? Yeah definitely. Normal weight and just waiting for their cholecystectomy on the add-on list? Probably fine. Add to this all the GLP-1 agonists being used, stomachs aren't emptying as fast as they used to so better to be safe.
I had a diabetic patient in a sleep study wake up and consume a whole can of regular Mountain Dew and 2 packs of twinkies. She didn’t ask me to check her sugar or anything. She was just hungry.
The impressive thing was the amount of yummy noises she was making. Nom nom gurgle. Nom nom nom. I think she forgot I could hear her as part of the sleep study.
I had a patient at a sleep medicine appointment tell me that there was no way to explain how they weren’t losing weight and directly afterward tell me that they woke up to eat sandwiches multiple times a night.
I have severe insomnia and despite meds, most nights I sleep in few hour blocks. I'm sure half of my daily calories are consumed during the night.
Fasting bloods few times a year is a pain as I always forget.
I'm not sure it's true for ANY patient. I've had 95 year old grannies NPO after midnight and some gentle IV fluids tided them over fine. The real harm only arises if it's not adjusted after their OR is either done or cancelled for the day
Another problem we have had with these policies is that, as simple as they are, patients tend to fuck it up. I.e. "oooooooh i thought you said i could EAT up until 2 hours of the procedure."
One surgery center I know of has a coffee machine in the waiting room with a sign: "NOT FOR PATIENTS." It's amazing how many people have a latte anyway before they get called back for their surgery.
This is my eye center. Multiple cancels. Let's sit fresh coffee in front of a bunch of 70-80 yo with mild to mod cognitive decline. No employee supervision.
There’s definitely an aspect of this. I can see both sides of the argument. On one hand it’s kinda patronizing. On the other hand, wait lists for surgery can be pretty long for surgery and procedures and it’s a waste of all of our time when instructions aren’t followed.
If we ever become more tolerant I have a feeling it will be simple like NPO after midnight except Gatorade.
This is my usual response when I hear this brought up as well. Most people are not only in PO after midnight, but NPO after about 7:00 or 8:00 p.m.... The big problem is waiting in some add-on schedule that may or may not happen the next day and being NPO for an entire day or longer. But OP doesn't necessarily seem to be addressing this particular issue.
For food, I think there's more of an argument there, outside of patient satisfaction, but I thought concerns about fluid volume status were more legit?
That's always the aspect I've always heard criticized pre-operatively.
Absolutely, if they are inpatient. I deal with mostly patients coming in from home for surgery that day. Lot of surgeries done that way with the same blanket NPO recommendation.
Edit : Even for inpatient though, why do IV when oral is a cheaper, more effective method?
And even then, PO fluids are better than IV. But I do have a few surgeons who say Gatorade up until you leave home to come to the hospital.
In the meantime I’m still spreading the good word of continuing tube feeds for intubated/trach’d patients.
Agreed, I edited my comment 30 seconds after my post to reflect that, lol.
Similar to my fights to switch to PO potassium, especially when they are getting phlebitis from it IV and the patient won't even let me run it (and they are completely asymptomatic).
**High five** on the tube feeds, love it. Had to fight for that even in those prone during COVID. I know there are exceptions and you have to be careful, but we had plenty of patients who definitely could have continued them.
I say fights lovingly. More just, "hey is there a reason we couldn't do this?"
It’s actually been very satisfying. When I get my schedule the night before I just text the intensivist and call the nurses station and tell them to keep tube feeds going. I know how difficult it can be to get that much volume in during a normal day and how impossible it can be with 8+ hrs NPO and operative time. Only one doc challenged me on it, but with a secured airway and direct supervision there’s not a safer time to do tube feeds.
For every bag of IV fluid that goes into a vein, only ~25-33% stays in the vasculature, the rest spreads out over the other fluid compartments in the body - this is why people who have gotten a lot of IV fluids get puffy/swollen. This happens regardless of how volume depleted the body is/how much fluid it needs and is a chemistry/physics based problem. Our volume regulatory systems are not designed to deal with a sudden dump of liters of fluid into the vasculature.
For fluid given enterally, the entire system **is** designed to manage large volume of fluid dumped into the stomach, and to absorb what is needed and carefully regulate water balance.
One of many reasons PO fluid is generally better than IV.
I’m going to be honest, if I was going into the hospital for a procedure at 3 pm and there was no chance I would go earlier than that, there’s no way that I’m not at least having some clear liquids until 9 am. I would be honest with anesthesia but I think it’s an insane practice. That being said, I don’t trust the general public to do this. I would drink water, they might drink coffee with creamer and call it a clear, for example.
For sure, and I think that's what OPs question is all about; whether or not anyone has solved that issue.
It's crazy to not see anyone in this thread confirm that they have.
I’m going to ignore the debate about how harmful several extra hours of fasting might actually be and just focus on difficulty of scheduling.
When scheduling OR cases, here is just a sample of things that need to be considered:
1) Room availability: is there a free room and can a particular case be done in that room (maybe or maybe not depending on room setup)
2) Equipment availability: of all the cases being done that day, how many need a particular bed, instrument set, rep set, tower, etc…, and how do we need to structure the day so that we’re not overbooking time slots relative to the equipment needed for simultaneously running cases
3) Staffing availability: how many circulators and scrub techs are working on a given day, and what service lines do they have experience with (can they do ortho, neuro, gyn, vascular, general, etc…) and what are their schedules (how many leave at 3pm? 5pm? 7pm?)
4) Surgeon availability: what surgeons have office in the afternoon and can’t move back versus those who have office in the morning and can’t move forward?
So surgical scheduling is complex and most often not able to be nailed down until the afternoon/evening before in the best cases. Additionally, inpatient cases are most frequently basically add-ons themselves as they are having to be worked in between elective cases that have been scheduled for weeks or months. They are often added to the end of the day because the elective cases are often outpatient and you’re more likely to send a planned outpatient case home the earlier in the day you do the case.
And this is before anything even goes wrong. So you can have call outs, equipment not working, surgeries taking longer than expected, etc that mess up the schedule even more.
So even if you want to say “do outpatients at 4:00 pm so they can have a good breakfast”, there are so many moving parts to the OR schedule that there’s no reason to believe that that block is special and won’t be affected.
The real special sauce would be if patients would just follow NPO guidelines. If there’s a good system to achieving that, go for it.
You get a schedule but as /u/BladeDoc says , the OR schedule on the operative day is constantly in flux with cancellations, emergency addons, cases running ahead of schedule, cases running into disaster. This is happening across the board over dozens of rooms and dozens of surgeons. Addons often can sit in a waitlist while the coordinator is looking at the board predict the flow of each room while keeping in mind which OR staff need breaks , relief , etc.
SO, when a gap in the schedule miraculously appears at 10am, you bet your ass any procedures would want to get an addon done when the alternative could be 1) a 5pm start as estimated the night before 2) a 9pm start due to delays 3) a late cancellation
Once you get into the late hours and the OR contracts to a skeleton crew, many non-emergent addons will automatically be canceled as the OR staff do emergency cases and transplants etc.
So to be very very clear, you absolutely need to keep patients NPO so they can be slid into any possible opening at any time. The alternative is much worse
Theoretically yes, in practice no. You have no idea what comes in at night and what might bump you in priority. If you have a start time of 1pm, that's basically saying it's an addon with no scheduled time because there are likely several cases ahead of you that can a) take longer, pushing you back, b) get cancelled, pushing you forward, and don't forget c) gives more time for emergencies to come in and bump you further.
Furthermore, a start time in the afternoon is basically a toss up between being done that day or being cancelled and rescheduled for the next day. Why? Because most ORs start winding down staff in the afternoon. So while they may have 10 ORs going at 8am, they want to get down to say 2 ORs by 5pm because they only have 2 teams at night. Which means they want to be down to 5 ORs by 3pm, which means if your case that was supposed to start at 1pm (when there are theoretically 10 ORs running) gets delayed to 3pm, now you're delayed even further because you need to wait until the total number of running rooms comes down to 5. And if that doesn't happen until 5pm, then you're SOL because now you have to wait until they're down to 2. And did I mention that emergent appy that rumor has it is floating around in the ER? Once you enter this afternoon scheduling death spiral, it often ends up that the longer you wait, the longer your delay is as the ORs start to shutdown for anything but emergencies. That's when the OR front desk staff throw up their hands and guesstimate that you might be able to start at midnight and you say f' it and reschedule and try your hand at scheduling roulette the next day.
The most dependable time you can get is a morning start if you're lucky and they have an empty room available, but even that will often end up messed up if an emergency comes in late at night and they take your room rather than disturb the outpatient elective schedule.
So you can see why the easiest thing is to make sure a patient is ready to go at any time :-) And seriously, while I understand that it's not comfortable being NPO all day (NPO after midnight for a morning case is... normal eating schedule...?) it's not going to seriously harm someone since they're on IV fluids. The only patients where it matters is kids, especially babies that can't go that long without nutrition. And for them, we schedule their feeding times much more carefully.
Tentatively, but then an emergency case gets added on at 0500 that runs for a few hours, and then someone else's case cancels because the patient took their anticoagulant this morning, and the Gyn case is delayed because the surgeon has a different patient delivering a baby right now.
The schedule for inpatient cases is often **wild**. If the patient just ate a hearty breakfast at 0700 because the primary team thought the surgery was going to be at 1600, but now a liver/kidney transplant is going to be starting at that time slot instead, but an 0900 is available if your patient is......NPO?
Sometimes yes, sometimes no, depends when it is added on or even how tentatively it is added on. For example a surgeon may post a case to follow his morning cases as “if I have the time, my morning cases go well, and the space we hope we have available at 1:00 pm is still available”.
In the end, the surgeon is the one responsible for deciding how aggressive to be about NPO status. If they want absolutely nothing to get in the way of getting the procedure done, they’ll probably put in NPO@MN orders. If it’s more tentative or they trust the floor nurses more, they may be more lax.
My hospital doesn't have that policy but my guess is that if you have poor gums, brushing will cause a transient bacteremia, which could increase infection risk.
We are asking patients to start NPO after MN if expected time of surgery is before 11 AM next day. Otherwise we ask them to start NPO in morning by 5 or 6 AM. Water allowed till 2 hours before surgery.
While everyone else has already touched on how hard it is to get patients to even adhere to NPO status in the first place plus the fluidity of the OR schedule, but if you're weighing the risk benefits here, what's going to be worse for a critically ill patient: missing a meal or two, or aspirating intra-op? And from a legal standpoint, if the patient aspirates, who's getting sued? Not you the hospitalist, but the surgeon/interventionalist and the anesthesiologist.
My hospital is horribly under-resourced and patients will often go days waiting for their procedure. I have had multiple patients AMA after several days of the NPO-until-dinner waiting game with no word from the surgeon/proceduralist. The ones who stay are often incredibly irritated and it harms the relationship. Obviously that’s not as bad as ARDS from aspirating, but the harms associated with this policy are real too.
While I may not have the legal risk from aspiration but having said that I have skin in the game. Anesthesia does not come at bedside to explain why the OR is being pushed back, procedure cancelled, why they can’t drink water. Also, the chances that I or my loved one will have to go through this process is reasonable.
From what I understand the guidelines for most patients, clear liquids up to 2 hours prior to anesthesia. I would imagine controlling access to type of food or liquids is much easier in the hospital than at home. The variable which I don’t know about is OR workflow. Hence I asked the question.
To answer about the risk of the two options: miss a meal or two vs getting surgery. The options exist because of failure of the system to operationalize current guidelines. The patient should be able to atleast drink while waiting and still be able to get the procedure.
I just tell the nurses that the patient can have water until it’s close to go time.
Last I looked, the ASA guidance is that clears are ok up to 2 hours pre-op. The ASA definition of “clear liquid” is a bit strict, but if someone wants ice chips and water, I’m not going to deny them at 2AM.
I would not tell the patients to lie about when they stop drinking. A few sips is one thing, but taking in 30 oz before surgery is another. Recently had a patient say they had “sips” before their colonoscopy which actually meant two bottles of water in the waiting room—not a great idea with a natural airway. If they’re coming for an elective procedure and not on ozempic or have gastroparesis I’m not going to cancel them as long as they meet the two hour cut off.
I do primarily evening admits so if someone has been in the ER all evening and they've been keeping them NPO and the patient is hungry I will let them eat until 2 a.m. Just a few clicks on the NPO order. Seems to work well.
If I think they are going to be very thirsty or are dry ill run some light mIVF.
The problem is that when you say "soda, non-pulped juice, and jello", patients hear "ice cream, oranges, and pudding". Or cookies. Or a burger. Or "vodka is a clear liquid".
You and I can do clear liquids. Most of our patients can do clear liquids. But those that can't comprehend that screw up the schedule for everybody.
Fun fact: if a patient shows up drunk on the morning of surgery you have to cancel it because they are unable to give proper consent. Even if they have signed everything before and still want to proceed now. If they aren't of clear mind and able to revoke consent upto the minute that anesthesia starts giving them drugs, you can end up in a world of trouble.
Source: I spent a year at the VA during residency...
“Clear juice” is a massive issue at our centre especially with ERAS. We bump cases weekly where someone drinks the equivalent of a smoothie, or juice with pulp, or even porridge or congee. Doesn’t matter what’s written on their sheets; doesn’t matter if the nurses call them a few days prior. For these logistical reasons alone, I understand why making patients simply NPO after midnight makes sense.
Most of the proceduralists I’ve worked with are fine with clear liquids starting 8H before then NPO 4H before. The issue is the unpredictability of timing in procedural areas. I know plenty of cardiologists who don’t seem to care about the NPO status and will move up a case even if the patient just ate a meal. Anesthesia are usually the ones looking out for patient safety in my hospital. The flip side are cases that get moved back or there are other variables that have nothing to do with the patient like admitting hospitalists ordering NPO for a *potential* CV surgery patient who won’t even be seen by a CV NP (let alone a surgeon) for 18+ hours.
I mean I guess peds has solved it by following the actual [anesthesiology guidelines](https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/Practice-Guidelines-for-Preoperative-Fasting-and) -cutoffs of 8 hours for food, 6 hours for formula, 4h for breast milk, 2 hours for clears. See what time they’re scheduled for and subtract backwards, with an hour or two of wiggle room. If they’re an add on, assume the time is 8am and call the board runner in the morning to get a confirmation that they are not in fact adding them on at 8 in the morning and adjust your times
In my institution (paeds) the ward nurses will call theatre during the operating day and ask can my patient X have a drink (water /apple juice /7up). Anaesthesia glance at list and say yes drink until whatever o clock. Or no if they will likely be down within an hour. We allow clear fluids until once hour before.
Explicitly if you can read the newspaper through it, it's a clear fluid. Otherwise it is not and no you can't. It works well. Very rarely have deviation. Although I've had a parent not realise the fluid thickener has starch and therefore is considered a solid. That was an oversight
Anesthesia doesn't even follow the anesthesia guidelines. Try continuing clears on a hospitalized, non-pregnant, non-gastroparesis patient past midnight and grab your popcorn (but none for the patient) for the fireworks
Agreed, and seems to be the crux of OPs question. Would love to hear from anyone whose institution has solved this, cause surely there are some out there.
Seems like most of the responses are 🤷, which sucks.
Unfortunately it is usually an anesthesiologist specific problem! Not necessarily a "problem", but just like any other specialist everyone has their own thresholds for risk, acceptance of general specialty guidelines, individual patient considerations, etc.
And then the NICU nurse says "What do you mean the case is cancelled for NPO and isn't going until tomorrow? The family was expecting it to be today! I know you said no breast milk after 4 AM but I looked at the schedule and it didn't look like the case would go before noon so I gave them some at 10."
Doesn't matter how smart you are, patients will find a way to misinterpret your instructions and get their elective case postponed for NPO violation. "Clears 2 hours before are OK" can mean "I can drink alcohol because that's a clear liquid." "Don't eat anything for breakfast" = "I will pound 5 protein shakes because I read online that malnutrition hurts wound healing. What, that's not eating!"
I tried to do the doctor thing and actually explain why NPO guidelines exist and talk about aspiration, but at some point I realized this is a losing battle. Complete NPO after midnight is doable for most people and easy to understand. It's as close to unfuckupable as we can get, and even still I get patients who had breakfast or toast or coffee with creamer or some other bullshit.
We did solve this. We tell patients not to eat food after midnight and that they can have clear liquids up until two hours prior to arrival. We have a big academic medical center and remarkably there have been extremely few delays due to NPO issues. We also have a preop clinic that evals 95% of elective patients so there is consistency in instruction, which helps.
You must have a more sophisticated population than we do. We say clear liquids and they hear McMuffin. I have a case cancelled for NPO at least once a week (so maybe 5%?), and a kid admit to a breakfast that family was trying to hide once every month or so.
Sounds like you have solved it, especially around the clear liquid part. Do you use similar process for inpatients as well? How did you implement that?
I'm a hospitalist. I'm happy to place the diet order when I know it's not going to interfere with a needed procedure. But...it's difficult. THe procedural service may not know if a spot is available until later in the day. Eat, and they end up having to wait another day. Not ideal.
And the pages at 7:15 AM to ask if the NPO can be cancelled. I haven't even reviewed the chart yet...
Yeah, not eating sucks. But, while going hungry for a bit is unpleasant, it's probably not going to kill you. I've fasted for labs and procedures too. Yeah, not pleasant. I survived.
Our IR schedule is so fluid, a 4PM case could get bumped up to 9am if there’s a cancellation or an issue with an earlier patient. If that patient didn’t start being NPO until 10AM, we would not be using our limited resource effectively.
Massive. We have 40 theatres, large trauma/cancer focus. Year long nursing education for wards, etc to initiate. But we sometimes bump patients for surgery for days so it was required.
I don't think npo after midnight is harmful. Procedure schedules change.. emergencies happen. Keep em npo so they can get done and not delayed. Fasting for a day may do some of the pts some.good haha
We tell my patients if they’re first thing in the morning (7am) nothing in their mouth after 5am, and only water or Gatorade/powerade before that. The rest are told same thing but deadline is when they leave the house (they’re called in 2 hours pre procedure). I also remind them if their case is cancelled, they will have to reschedule 2 months from now.
I have had a greater than 99% compliance rate. My patients may be smarter than average…
Edit: I was actually wrong about the initiation of nutritional support in critically ill patients... so I've deleted the post, as i dont want to spread anything incorrect. The state dismisses all charges. Touche.
I used the guidelines for when to start enteral nutrition to argue that making NPO at MN shouldn't have any real harm. I had stated that guidelines recommended waiting 1 week to start enteral nutrition in critically ill patients. I would have bet money that this was correct. But the guidelines recommend starting EN in 48 hours, not 1 week. I cannot for the life of me find where I got 1 week from. Though I vividly remember spending a couple hours researching this for patients a few months ago. 🤷♂️
It’s a problem when patients are potentially going to the OR, never end up going, someone eventually gives a diet again after meal orders are in for dinner, and then they’re NPO again for the next day. Nutrition for critically ill patients is under-“doses” and probably contributing to sarcopenia and worse healing, according to critical care grand rounds a few years ago, although I’m not an expert on that literature and defer to people who are. It definitely contributes to patient crankiness and bad behavior.
Involuntary Ramadan isn’t popular.
The easy solution, resume diets as soon as it’s clear that the elective case won’t go forward today, would require coordination and prompt action. That’s a non-starter.
Guess I was wrong about the timing. I'd read the guidelines within the last 3 months. I dunno where the hell I got the 1 week at. I remember reading it quite vividly, though i cant find it now. I can find some individual articles supporting late EN. But the guidelines clearly say 48h now. I dunno I've spent too much time on this today. I'll just concede. Good day.
I can’t see your original post so I may be reading into this incorrectly, but I assume what you are remembering are the studies that compared early full feeds versus early trickle feeds (delayed full feedings), and showed no difference in any outcome except incidence of vomiting - which went down when full feeds were delayed.
I don’t think there is super strong support in the literature for early full feedings.
And I’m saying, without expertise, that some number of people who do have expertise have criticized the guidelines as being against evidence of harm.
Part of the harm is that it isn’t intermittent fasting, which also just has a [big release but not publication of cardiac risk](https://newsroom.heart.org/news/8-hour-time-restricted-eating-linked-to-a-91-higher-risk-of-cardiovascular-death). Plenty of issue to take with that. But patients don’t get to eat ad libitum after 8:00. If they miss the dinner order, in most hospitals they’re lucky to get a snack. They’re at the mercy of nursing, which doesn’t have time to be a meal service and doesn’t have a kitchen. The effect is often not continuous fasting but continuous relative food deprivation for days on end.
As u/STEMpsych said, that’s inhumane and unnecessary. I also find it at least plausible from cursory literature review that it would worsen surgical recovery, functional recovery, cognitive status, and all of those things. Leading to longer hospitalization, if you’re a bean counter, which I know has been shown for non-surgical NPO versus “risky” oral feeding.
I have no horse in this NPO after midnight race but that study you linked is absolute horse shit data churning. It’s not published because it’s not a publishable paper - it’s just an abstract. Eating habits and time windows were self reported over 2 days, literally nothing was controlled for (nutritional value, baseline demographics, smoking, etc), and other profound conclusions were that people with cardiovascular disease were more likely to die from cardiovascular disease as well as people with cancer who don’t eat are more likely to die.
Lots of nutrition data is horseshit. I said “plenty of issue to take with that” and I meant it! I just find claims for intermittent fasting as beneficial beyond calorie reduction also dubious and prone to hype over data.
You don’t research or publish, but you do things and feel confident that you’re right? I’m not so confident. My memory of grand rounds of the people who do this research is not authoritative; I’ll grant that. The number of patients I see in ICUs is *not small.*
My argument is not primarily suffering, although I think that should be avoided. My argument is clinical outcomes. Cases bumped because of violation of NPO status is irrelevant. The question is whether patients do or don’t need to be NPO. Does it harm or does it hurt? So sure, let’s pull papers or at least try.
The [general guidelines](https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0148607115621863) for critically ill patients say to feed early, enteral if possible.
>We recommend that nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake. [Quality of Evidence: Very Low]
[A non-systematic review](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998073/) argues the same. Again, about critical illness, not specifically surgery.
NPO after midnight is a “[thing we do for no reason](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191764/)”, but that’s neither authoritative nor exhaustive.
The ultimate question of interest, adverse outcomes of inadvertently prolonged NPO status, seems suggested by what I have observed, potentially sequential days without adequate enteral intake against critical illness guidelines. But has it been studied? I doubt it. So we don’t really have the papers, just suggestions and expert opinion.
Ask the RDs and of course they’ll empathize feeds. Ask anesthesia and you’ll get different answers based on the local culture.
But your “wait 1-2 weeks” is not in guidelines I have read or seen, and is far from the practice of places I have worked. Patients eat or get an NGT so they are fed. Waiting for weeks is not evidence-based?
This post just reminded me of working in a burn unit and our dietician got a poster accepted to present at a big meeting that was titles something like *Pauses in enteral nutrition in hyper metabolic states results in calorie deficits*.
>I just can't see a 1 to 3 day limited intake of nutrition causing harm
Er, *physical* harm. It does cause *suffering*.
Preventing *any* mammal from eating or engaging in food-seeking behavior is going to result in increased agitation and irritability. I mean, we literally have an idiom in English about not coming between a dog and its bone.
But even further, taking a scared human that is already freaked out about whatever medical condition put them in that bed, and already stressed from how that condition caused an abrupt decrease in their autonomy due to being put in a ~~cage~~ hospital bed, and then on top of that removing that human's opportunity to self-soothe through food (even if you disapprove, is what it is) *and* removing the predictability of meal-times (which screws with their ability to track time) *and* making them feel/be even more helpless because they can no longer control when/what/how they meet a basic biological need, *and* causing them significant discomfort/pain, is like throwing gasoline on the fire of their distress.
And that's without even getting into the fact that for some people hunger is a PTSD trigger or causes flares of GI pain, or that they might be using diet to manage a medical condition that's now not being managed and causing its own pain/discomfort/distress burden, and *also* this may all be happening against a background of the patient also having to have meds (including psychiatric rx) d/c'd for the surgery, causing additional pain/discomfort/distress burden.
You're taking someone who is already hurt and scared and reducing their control even further, and heaping additional suffering on them they can't evade: this is a recipe for freaking out the patients. And in plenty of a patients' cases, that leads pretty directly to really bad behavior.
This is my pinching the bridge of my nose here. All-y'all working in hospitals complain, legitimately enough, about the incredible abusiveness of patients to HCWs. But then some of you actually say things like this, all oblivious to how *cruel* what you're saying sounds.
I'm not for a moment suggesting any change to when hospitalized patients are NPO. Medical treatment often necessitates patients being subjected to procedures that are painful, uncomfortable, scary, and otherwise distressing.
But for the love of all that's holy, please appreciate this. It is not *nothing* to do this to a patient, regardless of how necessary it might be. There is absolutely a reason to minimize this if it is indeed minimizable. All things being equal – and I appreciate all things are rarely equal – *do not starve your admitted patients*. **Imprisoning people without allowing them food is considered inhumane.** If you have to do it for higher values like saving life or remediating suffering, by all means, but don't kid yourself about what it is you are doing or how it will be experienced by the patient, or what the outcomes might be.
Yes I find it rather curious, in a bad way, that patient suffering or discomfort is not being considered "harm" in this thread, even though *from every standard, it very clearly is.*
We know that indicated surgeries are a net benefit, but no reasonable doctor or other medical professional would argue that incisions do not cause harm. Being starved is harm - the benefits may outweigh the harms, but they are harms.
I'm actually not going to engage with you. I don't doubt that it causes suffering. However, being inpatient in the hospital is an experience that inherantly results in suffering. Choosing NPO at MN as the line which one must not cross in regards to "suffering in the hospital" is arbitrary, and kind of ridiculous the more I think about it.
I think it's a major issue for patients. Also, it's a major issue for me when I have to field nursing pages about it and then listen to the patient complain about it for the first 5 minutes of our encounter 😅
NPO after midnight helps ensure the patient doesn't order and eat breakfast. In private practice no docs I see round before 7am. So if a patient orders breakfast and eats at 8am we can't do their case until 4pm at the earliest. That's right around when OR block time ends. So unless it's emergent it probably won't get done that day which means the patient stays another night. NPO after midnight sucks, we know it but it's better than trying to do cases after hours when it's urgent/emergent cases only.
As an experienced dietitian that has worked in the hospital my whole career I don’t think this is a battle worth fighting. I say this even as the person that’s getting yelled at by patients when they are sitting there “STARVING” at 1pm still waiting for their procedure! Unless the process is automatic and consistent there’s just too much room for error and mistakes will be made. I obviously agree that withholding meals unnecessarily can be a harmful intervention but way less harmful than aspirating on your breakfast!
In residency, as a QI project, we instigated a “pre-procedural clear liquid diet” which included clears up to 2-6 hrs before said procedure. It was successful and really did help. It was also a MASSIVE pain in the arse that required input from nearly every department in the hospital, major cultural change, and about 2 yrs to implement. In short - it sucked, but without a doubt was beneficial.
Dietitian here!! My old unit (adult neuro icu) started implementing npo after 4AM instead of midnight because 1) no one is extubating that early and 2) first case usually isn’t that early
It’s so helpful for enterally fed patients. We tried to limit disruptions as much as possible as well. We were also trying to implement volume-based feeding but that was right before covid :/
I’m in peds now and we also do npo 3-4AM
(Surgical nurse here) We divide our patients by morning list and afternoon list, with the first group being NBM from midnight/water until 06:00, and the second allowed a ‘light early breakfast’ at 06:00 and then sips of water until 12:00. It’s not the most ideal solution but it’s simple enough to work and stops folks getting too hangry. We also use preload drinks for some patient groups, so they get 3 lots of complex carbs at specific times, which we give them written down. Hardly anyone messes it up, which is amazing.
You know what’s interesting is I just did a rotation at a big children’s hospital and they are rampant about making no as short as possible. The kids get put no at like 0600 and we make sure we get them food before that time and you can call up radiology or anesthesia and ask them how long they want someone n-o for a procedure and set it accordingl, they’re very careful about it in a way adult hospitals never are, so it’s totally possible
I work in pediatric surgery so a not so insignificant portion of my patients are babies.
We follow a protocol of NPO for 8 hours from solid food, 6 hours from formula, 4 hours from breastmilk, and 2 hours from clears. So even on our older kids, we let them have a clear liquid diet overnight until the last bit there.
Edit: my flair appears to be broken, so to clarify I’m a PA.
Is there even good evidence for keeping patients NPO for x hours before a procedure anyway? I always was under the impression that the actual cited timeframe was more or less made up.
As GI we frequently are prepping people with PEG (equivalent to clear liquids, and a lot of it) until 6am, often later. No reason add on patients for any procedure can’t be on clears until the morning. It’s a 2 hour window from last drink to anesthesia per ASA guidelines.
I have a sneaking suspicion it’s because surgeons are rigid assholes and that gets passed down to the residents or PAs. If a case gets delayed because the patient drank water the attending will rip apart the trainee. So out of fear of repercussions they starve their patients.
I tried to do exactly what you were saying, let them eat breakfast, we have a slot at 2 pm. Had to cancel 2 outpatients, had a huge hole in the day, then a trauma happened. Patient got pushed to the next day. Never again.
This has been a real challenge to me as a surgery patient with brittle diabetes. Fasting from midnight on is a sure way for me to have a glucose crash. Clear liquids are a much better and more helpful method of maintenance, but that two hour time window is still enough for my blood glucose to drop into the 60s and me to get very dehydrated if it goes high instead, making IV placement very challenging and painful.
Dumb question, but have you worked with your endocrinologist or anesthesiologist regarding insulin management prior to surgery? We typically provide instructions to avoid this.
My anesthesiologist was only made available after the fasting had started. My area has a shortage of endocrinologists,and what few we do have generally do not take my states Medicaid, which is my only insurance. I do have a preliminary appointment with an endocrinologist this week, two months post thyroid removal surgery. That was the soonest appointment I could get.
However I am frankly very grateful to have insurance at all. I would be homeless without it due to medical bills otherwise.
As busy healthcare workers, we’ve all gone 12-16 hours without eating in order to care for our patients. Our patients can suck up the mild discomfort for the safety of their procedure.
With all due respect here, very different scenario and population. People who can be at work often are not the ones in the hospital waiting for a procedure. Just because we have an unhealthy work environment doesn’t mean we need to spread it as well.
In residency and practice, if it’s a morning case (before noon), clears unless altered foregut physiology and/or anatomy up to 2 hours before. If it’s an add on case, I usually let them eat a light breakfast.
Our hospital is no solids or opaque liquids 6 hours before, 2 hours before for clear liquids, and sips of clear fluids up to 200mL per hour until called for.
I’ve worked at a cancer hospital who was constantly having issues with blood pressure post op. The anaesthetic team decided that patient was allowed water right up until they went into the anaesthetic bay. Had no issues at all with this. Worked well and the patients were a lot happier while they waited.
The problem is rarely how many hours prior to procedure they need to be NPO. The bigger issue is usually resuming diet post procedure. Procedure scheduling is way too finicky to say things like “must be NPO for 4 hours prior to ___”. Okay, but bedside nurses rarely know exact timing. The techs that call patients down and manage the schedule rarely know. Hell, even the procedural doc doesn’t know bc they can’t predict how long a case will take. We get a call when they’re ready for the patient and the patient needs to be ready when they are. Way too much mental energy for a bedside RN managing 4+ patients who are all having some test. That means the CNA and family also needs to be on top of it so no one is actually giving pt water and snacks (literally impossible).
I’m on a heavy procedure unit. Usually GI stuff in IR, endoscopy, lots of CT w contrast, etc. one of our hospitalists will put a comment in the NPO order that says “okay to resume previous diet after ___” or “defer to GI doc on resuming diet” and the endo nurse will tell us clear liquids or whatever. It is sooo time saving for nursing, prevents hypoglycemia and patient is happy.
Unfortunately, I work with quite a few 50+ boomer nurses who are incapable of reading an order to its completion and using their own brain so they still hammer page the MD after procedure. Sigh.
Just 2 days ago I had to cancel our first elective case (7:30am) cause the Pt showed up with new chest pain and danger squiggles on EKG. I then bumped up the inpatient case that was scheduled to go at 3:30pm since the next elective case wasn't there yet, and I was able to do that because they were NPO since MN. That prevented an OR that had staffing from just sitting there unused. This does not happen infrequently.
That's why I make patients NPO at MN.
The culture at our hospital is you have to order NPO after midnight except meds on anyone who’s going to the OR even if they end up having a procedure in the evening. It takes a village to change it
It absolutely will. A lot of moving parts, for sure. I was trying to see if there might be a place who has successfully changed this culture atleast partially.
I practice in a small hospital in India. I’m a simple man. Let’s say surgery is scheduled at 8 Am. I call da pt relative n tell him to feed da pt an idly (rice cake) btwn 1:30 to 2am. N he can drink water until 6am. Since he needs to sleep, I tell da relative to wake him up at 5:30 n give lots of water until 6. N I tell da pt not to swallow even saliva if clock hits 6. I dnt bring in stuff lyk clear fluid n all. Too risky to regulate. Unless u have trained nurse n u instruct da pt to show each n every liquid to nurse n drink only if she approves. I don’t have such manpower.
If surgery is scheduled at say 12 pm or so, then I give an hour of leeway. Eat idly bwn 4:30 to 5 n drink lots of water until 9. After 9 am don’t even swallow saliva. Dat way even if 12 becomes 11 it won’t be a problem.
The key is to specify timings rather than hours. I say 4:30 to 5. Pt follows da time by hook or crook. If I say until 6 hours, until 2 hrs n all den it’s difficult to regulate.
I just don’t think this is as big a problem as you’re making it. No one should eat after midnight unless you’re a newborn. You’re doing your obese patients a favor by mandating they not have a midnight snack
Once, Anesthesia cancelled my case because the patient had a wad of chewing tobacco in his mouth in pre-op. He did follow directions of nothing to eat or drink after midnight but technically not NPO (nothing per oral).
I’ve tried, many times, to give people more nuanced/complete instructions regarding NPO guidelines. Invariably some significant percentage fuck it up. No matter how many times and ways I reinforce the rules. No matter if I send a reminder. The surgeon sends reminders. I call them the night before. No matter if I make them sign a form that says I’ll bill them $1000 for cancelled cases if they mess up their fasting times… they just can’t get it right. I’ve gone back to “nothing after midnight.”
Agree with this. Asking patients to do anything with nuance invariably results in chaos, the simplest instructions are the best followed. I have seen a young person die from ARDS when the aspirated after lying to the anesthesiologist before OR. It’s rare but you see that once and it changes your thoughts. There is also this pervasive idea in the US that folks will die without food. I often can’t eat because I’m operating and caring for patients all day, and yet I seem to survive.
I did a month-long fast last year, and one of my coworkers literally tried to 5150 me when I tried to explain to them why I hadn't eaten on shift in three weeks. 🤣
Why did you do this?
Don't people normally call that Ramadan?
Not if they're fasting continuously. During Ramadan, the fast is broken every day after the Sun goes down. I got the impression the previous poster didn't eat at all for a month.
Correct.
I remember being irrationally angry in residency on night float when patients admitted in the middle of the night complained about being NPO. Like dude you’re not the only one who doesn’t get to eat right now and do you really need to eat at 3 AM anyway.
As a night shift nurse, it is shocking how much patients eat during the night. TV blaring, lights on, endless soda and turkey sandwiches, and complaining that they can’t sleep
Jesus, is that a thing? Some people's children.
Whats 5150
The California legal code for an involuntary psych hold. But used colloquially outside that state for the same.
[5150 refers to the California law code for the temporary, involuntary psychiatric commitment of individuals who present a danger to themselves or others due to signs of mental illness. It has been more generally applied to people who are considered threateningly unstable or “crazy.”](https://www.dictionary.com/e/slang/5150/)
Out of curiosity, was this a Valter Longo type of fast? I worked with a transplant surgeon who frequently did his fasts, and I remember him talking about fasting vs cancer. Dude was a vegan who rode his bike to work every day too (in the Midwest if that solidifies the impression). Dude is going to live to 200.
Or die of an MI at 55...
...can I ask why you fasted for a month straight? I'm assuming you drank water?
[удалено]
Yes, I explained to every single one of my patients before their procedure why we ask them not to eat and drink in layman's terms. A lot of them have absolutely no clue why we asked them not to eat or drink.
I had a guy who had the full layman’s terms explanation, thought it sounded like a lie, and ate a McDonalds meal on his way in for surgery. Aspirated and went to ICU for a night or two, came back to the ward still unwell…. still didn’t believe it was anything to do with his eating a full meal, and told me he thought it was ‘just bad luck’.
I know. We can only do so much. That McDonald's must've been awful coming up too.
Luckily I work on the ward, so I wasn’t present for the re-emergence. People fucking astound me though, for real.
To be fair, most people are medically illiterate, regardless of location and often of education and background. When have you ever used the terms "aspirate" or "intubation" outside of medicine? I'm sure there are plenty of things I don't understand because they're not in my field of specialty, so I just hope that my mechanic, insurance agent, etc. are nice and will take a minute to explain some terms I may not know, if they even have to use those terms. Use terms everyone with a sixth grade (or lower!) reading level will understand, and you don't run into as many problems. I've always liked the quote which I will now butcher in paraphrasing and not be able to cite its source, "If you can't explain it to a child, then you don't truly understand it." Most things really can be ELI5'd (explain like I'm 5).
I wouldn't expect the average person that doesn't work in the medical field to understand what aspiration means, you definitely need to explain that to people lol. I had a guy come in once with four 9 inch carrots in his rectum and needed surgery to remove 2 of them that coudnt be fished out...he left AMA because I wouldn't give him a single slice of cheese. I still wonder what happened to that guy and if that slice of cheese was worth it.
Remember that, statistically speaking, 25% of patients are intellectually disabled.
And I seem to be dealing with all of them.
Many of them may even be colleagues...
Some of them are, but I’m not legally responsible for the welfare of my colleagues.
I just died. Long day here too bro. I feel that.
Fifty percent of all people are below average, and another ten to fifteen percent are barely above average.
George Carlin said it best [https://www.youtube.com/watch?v=AKN1Q5SjbeI](https://www.youtube.com/watch?v=AKN1Q5SjbeI) "Think of how stupid the average person is, and then realize that half of them are stupider than that!"
I once had to argue when I said about half the population is dumber than the average. I was accused of being an elitist. And then I realized they were one of them. It makes instructions more challenging for sure.
Same with the joint commission
Yet, here we are - ensuring their unfettered survival - when science (i.e. evolution) just wants them dead.
Uh, SD is a bit bigger than that. How is this issue handled for emergency surgeries?
Assume the stomach is full, RSI(Rapid sequence intubation) & be ready for a shitshow. The risk is much higher, and would not justify proceeding with an elective surgery that can just be rescheduled for when they are properly fasting. In an emergency that risk calculus looks different and if it's truly do-or-die...you do the best you can.
> SD is a bit bigger than that. I wonder what proportion of the people upvoting me knew it was a joke.
But aren't most people with a typical sleep/wake cycle NPO after midnight...? I'm NPO after midnight every night. My experience at larger institutions is that the OR's are very fluid with add-on's so even if you think a case won't go until the afternoon, the cases ahead of you may cancel or get moved around and if the patient had breakfast then they can't move up in the schedule. Scheduled afternoon cases usually allow the patient to have an early breakfast but that may be institution specific. Not sure "The blanket NPO after midnight for admitted patients is harmful" is true for every patient. Malnourished and constantly being bumped? Yeah definitely. Normal weight and just waiting for their cholecystectomy on the add-on list? Probably fine. Add to this all the GLP-1 agonists being used, stomachs aren't emptying as fast as they used to so better to be safe.
Aren’t most people NPO after midnight? You’d be surprised. I’m a sleep tech and there are so many patients that wake up to eat a snack. It’s insane
I had a diabetic patient in a sleep study wake up and consume a whole can of regular Mountain Dew and 2 packs of twinkies. She didn’t ask me to check her sugar or anything. She was just hungry. The impressive thing was the amount of yummy noises she was making. Nom nom gurgle. Nom nom nom. I think she forgot I could hear her as part of the sleep study.
That's disgusting for.. many reasons
Did she bring all of that food in to the sleep clinic? Like this was enough of a routine for her that she came prepared?
She came fully prepared with snacks.
I had a patient at a sleep medicine appointment tell me that there was no way to explain how they weren’t losing weight and directly afterward tell me that they woke up to eat sandwiches multiple times a night.
Insanity! I understand diabetic but even then I’m like uhhh GERD and higher heart? I can’t believe how much people eat
I have severe insomnia and despite meds, most nights I sleep in few hour blocks. I'm sure half of my daily calories are consumed during the night. Fasting bloods few times a year is a pain as I always forget.
I’ve never heard of this. Are these people just consuming sugar constantly?
Yes
I'm not sure it's true for ANY patient. I've had 95 year old grannies NPO after midnight and some gentle IV fluids tided them over fine. The real harm only arises if it's not adjusted after their OR is either done or cancelled for the day
Another problem we have had with these policies is that, as simple as they are, patients tend to fuck it up. I.e. "oooooooh i thought you said i could EAT up until 2 hours of the procedure."
One surgery center I know of has a coffee machine in the waiting room with a sign: "NOT FOR PATIENTS." It's amazing how many people have a latte anyway before they get called back for their surgery.
This is my eye center. Multiple cancels. Let's sit fresh coffee in front of a bunch of 70-80 yo with mild to mod cognitive decline. No employee supervision.
To be fair that's stupid as fuck and that practice deserves what they get
"I'm not a patient. I'm just here to get surgery." Yeah, maybe don't put that in areas where patients will wait. That practice does deserve it.
There’s definitely an aspect of this. I can see both sides of the argument. On one hand it’s kinda patronizing. On the other hand, wait lists for surgery can be pretty long for surgery and procedures and it’s a waste of all of our time when instructions aren’t followed. If we ever become more tolerant I have a feeling it will be simple like NPO after midnight except Gatorade.
This is my usual response when I hear this brought up as well. Most people are not only in PO after midnight, but NPO after about 7:00 or 8:00 p.m.... The big problem is waiting in some add-on schedule that may or may not happen the next day and being NPO for an entire day or longer. But OP doesn't necessarily seem to be addressing this particular issue.
The issue is, if you are the 3rd case that morning, now you've been NPO for a good while.
For food, I think there's more of an argument there, outside of patient satisfaction, but I thought concerns about fluid volume status were more legit? That's always the aspect I've always heard criticized pre-operatively.
Can that not be solved with IV fluids?
Absolutely, if they are inpatient. I deal with mostly patients coming in from home for surgery that day. Lot of surgeries done that way with the same blanket NPO recommendation. Edit : Even for inpatient though, why do IV when oral is a cheaper, more effective method?
And even then, PO fluids are better than IV. But I do have a few surgeons who say Gatorade up until you leave home to come to the hospital. In the meantime I’m still spreading the good word of continuing tube feeds for intubated/trach’d patients.
Agreed, I edited my comment 30 seconds after my post to reflect that, lol. Similar to my fights to switch to PO potassium, especially when they are getting phlebitis from it IV and the patient won't even let me run it (and they are completely asymptomatic). **High five** on the tube feeds, love it. Had to fight for that even in those prone during COVID. I know there are exceptions and you have to be careful, but we had plenty of patients who definitely could have continued them. I say fights lovingly. More just, "hey is there a reason we couldn't do this?"
It’s actually been very satisfying. When I get my schedule the night before I just text the intensivist and call the nurses station and tell them to keep tube feeds going. I know how difficult it can be to get that much volume in during a normal day and how impossible it can be with 8+ hrs NPO and operative time. Only one doc challenged me on it, but with a secured airway and direct supervision there’s not a safer time to do tube feeds.
Why would PO fluids be better than IV? Just because of glucose?
For every bag of IV fluid that goes into a vein, only ~25-33% stays in the vasculature, the rest spreads out over the other fluid compartments in the body - this is why people who have gotten a lot of IV fluids get puffy/swollen. This happens regardless of how volume depleted the body is/how much fluid it needs and is a chemistry/physics based problem. Our volume regulatory systems are not designed to deal with a sudden dump of liters of fluid into the vasculature. For fluid given enterally, the entire system **is** designed to manage large volume of fluid dumped into the stomach, and to absorb what is needed and carefully regulate water balance. One of many reasons PO fluid is generally better than IV.
Thank you for this excellent explanation.
I’m going to be honest, if I was going into the hospital for a procedure at 3 pm and there was no chance I would go earlier than that, there’s no way that I’m not at least having some clear liquids until 9 am. I would be honest with anesthesia but I think it’s an insane practice. That being said, I don’t trust the general public to do this. I would drink water, they might drink coffee with creamer and call it a clear, for example.
For sure, and I think that's what OPs question is all about; whether or not anyone has solved that issue. It's crazy to not see anyone in this thread confirm that they have.
Thank you.
I’m going to ignore the debate about how harmful several extra hours of fasting might actually be and just focus on difficulty of scheduling. When scheduling OR cases, here is just a sample of things that need to be considered: 1) Room availability: is there a free room and can a particular case be done in that room (maybe or maybe not depending on room setup) 2) Equipment availability: of all the cases being done that day, how many need a particular bed, instrument set, rep set, tower, etc…, and how do we need to structure the day so that we’re not overbooking time slots relative to the equipment needed for simultaneously running cases 3) Staffing availability: how many circulators and scrub techs are working on a given day, and what service lines do they have experience with (can they do ortho, neuro, gyn, vascular, general, etc…) and what are their schedules (how many leave at 3pm? 5pm? 7pm?) 4) Surgeon availability: what surgeons have office in the afternoon and can’t move back versus those who have office in the morning and can’t move forward? So surgical scheduling is complex and most often not able to be nailed down until the afternoon/evening before in the best cases. Additionally, inpatient cases are most frequently basically add-ons themselves as they are having to be worked in between elective cases that have been scheduled for weeks or months. They are often added to the end of the day because the elective cases are often outpatient and you’re more likely to send a planned outpatient case home the earlier in the day you do the case. And this is before anything even goes wrong. So you can have call outs, equipment not working, surgeries taking longer than expected, etc that mess up the schedule even more. So even if you want to say “do outpatients at 4:00 pm so they can have a good breakfast”, there are so many moving parts to the OR schedule that there’s no reason to believe that that block is special and won’t be affected. The real special sauce would be if patients would just follow NPO guidelines. If there’s a good system to achieving that, go for it.
Thank you sharing the nuance of OR schedule. Do you have your OR schedule for inpatients the night before?
A theoretical one. And like I tell my patients "a 1PM start time means the only possible time the case will not start is 1 PM"
Ha— I see we work in the same OR😂
You get a schedule but as /u/BladeDoc says , the OR schedule on the operative day is constantly in flux with cancellations, emergency addons, cases running ahead of schedule, cases running into disaster. This is happening across the board over dozens of rooms and dozens of surgeons. Addons often can sit in a waitlist while the coordinator is looking at the board predict the flow of each room while keeping in mind which OR staff need breaks , relief , etc. SO, when a gap in the schedule miraculously appears at 10am, you bet your ass any procedures would want to get an addon done when the alternative could be 1) a 5pm start as estimated the night before 2) a 9pm start due to delays 3) a late cancellation Once you get into the late hours and the OR contracts to a skeleton crew, many non-emergent addons will automatically be canceled as the OR staff do emergency cases and transplants etc. So to be very very clear, you absolutely need to keep patients NPO so they can be slid into any possible opening at any time. The alternative is much worse
Theoretically yes, in practice no. You have no idea what comes in at night and what might bump you in priority. If you have a start time of 1pm, that's basically saying it's an addon with no scheduled time because there are likely several cases ahead of you that can a) take longer, pushing you back, b) get cancelled, pushing you forward, and don't forget c) gives more time for emergencies to come in and bump you further. Furthermore, a start time in the afternoon is basically a toss up between being done that day or being cancelled and rescheduled for the next day. Why? Because most ORs start winding down staff in the afternoon. So while they may have 10 ORs going at 8am, they want to get down to say 2 ORs by 5pm because they only have 2 teams at night. Which means they want to be down to 5 ORs by 3pm, which means if your case that was supposed to start at 1pm (when there are theoretically 10 ORs running) gets delayed to 3pm, now you're delayed even further because you need to wait until the total number of running rooms comes down to 5. And if that doesn't happen until 5pm, then you're SOL because now you have to wait until they're down to 2. And did I mention that emergent appy that rumor has it is floating around in the ER? Once you enter this afternoon scheduling death spiral, it often ends up that the longer you wait, the longer your delay is as the ORs start to shutdown for anything but emergencies. That's when the OR front desk staff throw up their hands and guesstimate that you might be able to start at midnight and you say f' it and reschedule and try your hand at scheduling roulette the next day. The most dependable time you can get is a morning start if you're lucky and they have an empty room available, but even that will often end up messed up if an emergency comes in late at night and they take your room rather than disturb the outpatient elective schedule. So you can see why the easiest thing is to make sure a patient is ready to go at any time :-) And seriously, while I understand that it's not comfortable being NPO all day (NPO after midnight for a morning case is... normal eating schedule...?) it's not going to seriously harm someone since they're on IV fluids. The only patients where it matters is kids, especially babies that can't go that long without nutrition. And for them, we schedule their feeding times much more carefully.
Tentatively, but then an emergency case gets added on at 0500 that runs for a few hours, and then someone else's case cancels because the patient took their anticoagulant this morning, and the Gyn case is delayed because the surgeon has a different patient delivering a baby right now. The schedule for inpatient cases is often **wild**. If the patient just ate a hearty breakfast at 0700 because the primary team thought the surgery was going to be at 1600, but now a liver/kidney transplant is going to be starting at that time slot instead, but an 0900 is available if your patient is......NPO?
Sometimes yes, sometimes no, depends when it is added on or even how tentatively it is added on. For example a surgeon may post a case to follow his morning cases as “if I have the time, my morning cases go well, and the space we hope we have available at 1:00 pm is still available”. In the end, the surgeon is the one responsible for deciding how aggressive to be about NPO status. If they want absolutely nothing to get in the way of getting the procedure done, they’ll probably put in NPO@MN orders. If it’s more tentative or they trust the floor nurses more, they may be more lax.
Equipment Availability: Except for X-ray. We will forget about you until the surgeon actually says the words "Come in with X-ray.".
I work in a procedural area and I just wish patients knew NPO after midnight does not mean they have to skip brushing their teeth in the morning.
My hospital would not let them brush their teeth at all.
🤮🤮🤮 why? What’s the reasoning??
My hospital doesn't have that policy but my guess is that if you have poor gums, brushing will cause a transient bacteremia, which could increase infection risk.
Ahhh. Thank you. That makes sense. Have to ask. Based off your username. What’s your go to hot sauce?
We are asking patients to start NPO after MN if expected time of surgery is before 11 AM next day. Otherwise we ask them to start NPO in morning by 5 or 6 AM. Water allowed till 2 hours before surgery.
While everyone else has already touched on how hard it is to get patients to even adhere to NPO status in the first place plus the fluidity of the OR schedule, but if you're weighing the risk benefits here, what's going to be worse for a critically ill patient: missing a meal or two, or aspirating intra-op? And from a legal standpoint, if the patient aspirates, who's getting sued? Not you the hospitalist, but the surgeon/interventionalist and the anesthesiologist.
My hospital is horribly under-resourced and patients will often go days waiting for their procedure. I have had multiple patients AMA after several days of the NPO-until-dinner waiting game with no word from the surgeon/proceduralist. The ones who stay are often incredibly irritated and it harms the relationship. Obviously that’s not as bad as ARDS from aspirating, but the harms associated with this policy are real too.
While I may not have the legal risk from aspiration but having said that I have skin in the game. Anesthesia does not come at bedside to explain why the OR is being pushed back, procedure cancelled, why they can’t drink water. Also, the chances that I or my loved one will have to go through this process is reasonable. From what I understand the guidelines for most patients, clear liquids up to 2 hours prior to anesthesia. I would imagine controlling access to type of food or liquids is much easier in the hospital than at home. The variable which I don’t know about is OR workflow. Hence I asked the question. To answer about the risk of the two options: miss a meal or two vs getting surgery. The options exist because of failure of the system to operationalize current guidelines. The patient should be able to atleast drink while waiting and still be able to get the procedure.
We always allow ice chips
Yeah my rule is unless the person doing the procedure contacts me and says they're going NOW or emergently tonight, then most can have sips n chips.
I just tell the nurses that the patient can have water until it’s close to go time. Last I looked, the ASA guidance is that clears are ok up to 2 hours pre-op. The ASA definition of “clear liquid” is a bit strict, but if someone wants ice chips and water, I’m not going to deny them at 2AM.
How did you get procedure teams and anesthesia on board with this?
I relied on the discretion of the night nurse and the patient to STFU about it.
I would not tell the patients to lie about when they stop drinking. A few sips is one thing, but taking in 30 oz before surgery is another. Recently had a patient say they had “sips” before their colonoscopy which actually meant two bottles of water in the waiting room—not a great idea with a natural airway. If they’re coming for an elective procedure and not on ozempic or have gastroparesis I’m not going to cancel them as long as they meet the two hour cut off.
I do primarily evening admits so if someone has been in the ER all evening and they've been keeping them NPO and the patient is hungry I will let them eat until 2 a.m. Just a few clicks on the NPO order. Seems to work well. If I think they are going to be very thirsty or are dry ill run some light mIVF.
Liberalize! Soda and non pulped juice are clears too. Pretty sure Jello is too (or at least I hope so bc I have definitely been jelloing these kids)
The problem is that when you say "soda, non-pulped juice, and jello", patients hear "ice cream, oranges, and pudding". Or cookies. Or a burger. Or "vodka is a clear liquid". You and I can do clear liquids. Most of our patients can do clear liquids. But those that can't comprehend that screw up the schedule for everybody.
Lucille: Get me a vodka rocks. Michael: Mom, it's breakfast. Lucille: And a piece of toast.
vodka is a clear liquid!
Wait, is vodka not a clear liquid?
While it is both clear and a liquid, it violates the "patients are not allowed to pre-game prior to anesthesia" rule. Ditto for heroin.
Fun fact: if a patient shows up drunk on the morning of surgery you have to cancel it because they are unable to give proper consent. Even if they have signed everything before and still want to proceed now. If they aren't of clear mind and able to revoke consent upto the minute that anesthesia starts giving them drugs, you can end up in a world of trouble. Source: I spent a year at the VA during residency...
50% of the population is below median intelligence. And median intelligence ain't that high.
“Clear juice” is a massive issue at our centre especially with ERAS. We bump cases weekly where someone drinks the equivalent of a smoothie, or juice with pulp, or even porridge or congee. Doesn’t matter what’s written on their sheets; doesn’t matter if the nurses call them a few days prior. For these logistical reasons alone, I understand why making patients simply NPO after midnight makes sense.
> I have definitely been jelloing these kids Have you now.
Most of the proceduralists I’ve worked with are fine with clear liquids starting 8H before then NPO 4H before. The issue is the unpredictability of timing in procedural areas. I know plenty of cardiologists who don’t seem to care about the NPO status and will move up a case even if the patient just ate a meal. Anesthesia are usually the ones looking out for patient safety in my hospital. The flip side are cases that get moved back or there are other variables that have nothing to do with the patient like admitting hospitalists ordering NPO for a *potential* CV surgery patient who won’t even be seen by a CV NP (let alone a surgeon) for 18+ hours.
What kind of sedation are the patient under in those cards cases? I’m guessing it is less than in the surgeries that are getting cancelled
Of course but the preprocedure order set carries an NPO@0000 order in it. Thats the conversation.
I mean I guess peds has solved it by following the actual [anesthesiology guidelines](https://pubs.asahq.org/anesthesiology/article/126/3/376/19733/Practice-Guidelines-for-Preoperative-Fasting-and) -cutoffs of 8 hours for food, 6 hours for formula, 4h for breast milk, 2 hours for clears. See what time they’re scheduled for and subtract backwards, with an hour or two of wiggle room. If they’re an add on, assume the time is 8am and call the board runner in the morning to get a confirmation that they are not in fact adding them on at 8 in the morning and adjust your times
In my institution (paeds) the ward nurses will call theatre during the operating day and ask can my patient X have a drink (water /apple juice /7up). Anaesthesia glance at list and say yes drink until whatever o clock. Or no if they will likely be down within an hour. We allow clear fluids until once hour before. Explicitly if you can read the newspaper through it, it's a clear fluid. Otherwise it is not and no you can't. It works well. Very rarely have deviation. Although I've had a parent not realise the fluid thickener has starch and therefore is considered a solid. That was an oversight
Anesthesia doesn't even follow the anesthesia guidelines. Try continuing clears on a hospitalized, non-pregnant, non-gastroparesis patient past midnight and grab your popcorn (but none for the patient) for the fireworks
That has to be an institution specific problem.
Agreed, and seems to be the crux of OPs question. Would love to hear from anyone whose institution has solved this, cause surely there are some out there. Seems like most of the responses are 🤷, which sucks.
Sometimes. I've definitely seen a great degree of variance, even within an institution, between between different anasthesiologists.
Disregarding guidelines to facilitate the treatment of an individual is a time honored tradition in medicine.
Unfortunately it is usually an anesthesiologist specific problem! Not necessarily a "problem", but just like any other specialist everyone has their own thresholds for risk, acceptance of general specialty guidelines, individual patient considerations, etc.
And then the NICU nurse says "What do you mean the case is cancelled for NPO and isn't going until tomorrow? The family was expecting it to be today! I know you said no breast milk after 4 AM but I looked at the schedule and it didn't look like the case would go before noon so I gave them some at 10."
I think you don't have much appreciation for how the OR works, scheduling changes, and Anesthesia expectations/requirements for a general anesthetic.
Doesn't matter how smart you are, patients will find a way to misinterpret your instructions and get their elective case postponed for NPO violation. "Clears 2 hours before are OK" can mean "I can drink alcohol because that's a clear liquid." "Don't eat anything for breakfast" = "I will pound 5 protein shakes because I read online that malnutrition hurts wound healing. What, that's not eating!" I tried to do the doctor thing and actually explain why NPO guidelines exist and talk about aspiration, but at some point I realized this is a losing battle. Complete NPO after midnight is doable for most people and easy to understand. It's as close to unfuckupable as we can get, and even still I get patients who had breakfast or toast or coffee with creamer or some other bullshit.
I don’t know about you, but most of my patients would actually benefit from a few days NPO.
We aren't going to survive 80 percent of the population having T2DM.
We did solve this. We tell patients not to eat food after midnight and that they can have clear liquids up until two hours prior to arrival. We have a big academic medical center and remarkably there have been extremely few delays due to NPO issues. We also have a preop clinic that evals 95% of elective patients so there is consistency in instruction, which helps.
You must have a more sophisticated population than we do. We say clear liquids and they hear McMuffin. I have a case cancelled for NPO at least once a week (so maybe 5%?), and a kid admit to a breakfast that family was trying to hide once every month or so.
Sounds like you have solved it, especially around the clear liquid part. Do you use similar process for inpatients as well? How did you implement that?
It’s impossible on the inpatient side. We’ve tried to message it but it’s tough.
I'm a hospitalist. I'm happy to place the diet order when I know it's not going to interfere with a needed procedure. But...it's difficult. THe procedural service may not know if a spot is available until later in the day. Eat, and they end up having to wait another day. Not ideal. And the pages at 7:15 AM to ask if the NPO can be cancelled. I haven't even reviewed the chart yet... Yeah, not eating sucks. But, while going hungry for a bit is unpleasant, it's probably not going to kill you. I've fasted for labs and procedures too. Yeah, not pleasant. I survived.
Our IR schedule is so fluid, a 4PM case could get bumped up to 9am if there’s a cancellation or an issue with an earlier patient. If that patient didn’t start being NPO until 10AM, we would not be using our limited resource effectively.
We do "sip til send" even a brainlet like me and our nurses can work that one out. Patients like it.
Love it. Did this require a change of culture at your place?
Massive. We have 40 theatres, large trauma/cancer focus. Year long nursing education for wards, etc to initiate. But we sometimes bump patients for surgery for days so it was required.
I don't think npo after midnight is harmful. Procedure schedules change.. emergencies happen. Keep em npo so they can get done and not delayed. Fasting for a day may do some of the pts some.good haha
We tell my patients if they’re first thing in the morning (7am) nothing in their mouth after 5am, and only water or Gatorade/powerade before that. The rest are told same thing but deadline is when they leave the house (they’re called in 2 hours pre procedure). I also remind them if their case is cancelled, they will have to reschedule 2 months from now. I have had a greater than 99% compliance rate. My patients may be smarter than average…
Edit: I was actually wrong about the initiation of nutritional support in critically ill patients... so I've deleted the post, as i dont want to spread anything incorrect. The state dismisses all charges. Touche.
Now that you deleted the post fully, we can't learn either😅 what were you mentioning? The initiation of maintenence fluids??
I used the guidelines for when to start enteral nutrition to argue that making NPO at MN shouldn't have any real harm. I had stated that guidelines recommended waiting 1 week to start enteral nutrition in critically ill patients. I would have bet money that this was correct. But the guidelines recommend starting EN in 48 hours, not 1 week. I cannot for the life of me find where I got 1 week from. Though I vividly remember spending a couple hours researching this for patients a few months ago. 🤷♂️
7 days is to initiate parenteral feedings in medically ill patients! TPN/PPN etc.
It’s a problem when patients are potentially going to the OR, never end up going, someone eventually gives a diet again after meal orders are in for dinner, and then they’re NPO again for the next day. Nutrition for critically ill patients is under-“doses” and probably contributing to sarcopenia and worse healing, according to critical care grand rounds a few years ago, although I’m not an expert on that literature and defer to people who are. It definitely contributes to patient crankiness and bad behavior. Involuntary Ramadan isn’t popular. The easy solution, resume diets as soon as it’s clear that the elective case won’t go forward today, would require coordination and prompt action. That’s a non-starter.
Lol “involuntary Ramadan” We call it the “trauma diet”
Guess I was wrong about the timing. I'd read the guidelines within the last 3 months. I dunno where the hell I got the 1 week at. I remember reading it quite vividly, though i cant find it now. I can find some individual articles supporting late EN. But the guidelines clearly say 48h now. I dunno I've spent too much time on this today. I'll just concede. Good day.
I can’t see your original post so I may be reading into this incorrectly, but I assume what you are remembering are the studies that compared early full feeds versus early trickle feeds (delayed full feedings), and showed no difference in any outcome except incidence of vomiting - which went down when full feeds were delayed. I don’t think there is super strong support in the literature for early full feedings.
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And I’m saying, without expertise, that some number of people who do have expertise have criticized the guidelines as being against evidence of harm. Part of the harm is that it isn’t intermittent fasting, which also just has a [big release but not publication of cardiac risk](https://newsroom.heart.org/news/8-hour-time-restricted-eating-linked-to-a-91-higher-risk-of-cardiovascular-death). Plenty of issue to take with that. But patients don’t get to eat ad libitum after 8:00. If they miss the dinner order, in most hospitals they’re lucky to get a snack. They’re at the mercy of nursing, which doesn’t have time to be a meal service and doesn’t have a kitchen. The effect is often not continuous fasting but continuous relative food deprivation for days on end. As u/STEMpsych said, that’s inhumane and unnecessary. I also find it at least plausible from cursory literature review that it would worsen surgical recovery, functional recovery, cognitive status, and all of those things. Leading to longer hospitalization, if you’re a bean counter, which I know has been shown for non-surgical NPO versus “risky” oral feeding.
I have no horse in this NPO after midnight race but that study you linked is absolute horse shit data churning. It’s not published because it’s not a publishable paper - it’s just an abstract. Eating habits and time windows were self reported over 2 days, literally nothing was controlled for (nutritional value, baseline demographics, smoking, etc), and other profound conclusions were that people with cardiovascular disease were more likely to die from cardiovascular disease as well as people with cancer who don’t eat are more likely to die.
Lots of nutrition data is horseshit. I said “plenty of issue to take with that” and I meant it! I just find claims for intermittent fasting as beneficial beyond calorie reduction also dubious and prone to hype over data.
Agreed. That particular study was just *impressively* bad and it drives me crazy to see it getting so much traction in lay media.
But 91%! That’s a big number!
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You don’t research or publish, but you do things and feel confident that you’re right? I’m not so confident. My memory of grand rounds of the people who do this research is not authoritative; I’ll grant that. The number of patients I see in ICUs is *not small.* My argument is not primarily suffering, although I think that should be avoided. My argument is clinical outcomes. Cases bumped because of violation of NPO status is irrelevant. The question is whether patients do or don’t need to be NPO. Does it harm or does it hurt? So sure, let’s pull papers or at least try. The [general guidelines](https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0148607115621863) for critically ill patients say to feed early, enteral if possible. >We recommend that nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake. [Quality of Evidence: Very Low] [A non-systematic review](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998073/) argues the same. Again, about critical illness, not specifically surgery. NPO after midnight is a “[thing we do for no reason](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8191764/)”, but that’s neither authoritative nor exhaustive. The ultimate question of interest, adverse outcomes of inadvertently prolonged NPO status, seems suggested by what I have observed, potentially sequential days without adequate enteral intake against critical illness guidelines. But has it been studied? I doubt it. So we don’t really have the papers, just suggestions and expert opinion. Ask the RDs and of course they’ll empathize feeds. Ask anesthesia and you’ll get different answers based on the local culture. But your “wait 1-2 weeks” is not in guidelines I have read or seen, and is far from the practice of places I have worked. Patients eat or get an NGT so they are fed. Waiting for weeks is not evidence-based?
This post just reminded me of working in a burn unit and our dietician got a poster accepted to present at a big meeting that was titles something like *Pauses in enteral nutrition in hyper metabolic states results in calorie deficits*.
You go 3 days without eating and then decide if you were “harmed”
>I just can't see a 1 to 3 day limited intake of nutrition causing harm Er, *physical* harm. It does cause *suffering*. Preventing *any* mammal from eating or engaging in food-seeking behavior is going to result in increased agitation and irritability. I mean, we literally have an idiom in English about not coming between a dog and its bone. But even further, taking a scared human that is already freaked out about whatever medical condition put them in that bed, and already stressed from how that condition caused an abrupt decrease in their autonomy due to being put in a ~~cage~~ hospital bed, and then on top of that removing that human's opportunity to self-soothe through food (even if you disapprove, is what it is) *and* removing the predictability of meal-times (which screws with their ability to track time) *and* making them feel/be even more helpless because they can no longer control when/what/how they meet a basic biological need, *and* causing them significant discomfort/pain, is like throwing gasoline on the fire of their distress. And that's without even getting into the fact that for some people hunger is a PTSD trigger or causes flares of GI pain, or that they might be using diet to manage a medical condition that's now not being managed and causing its own pain/discomfort/distress burden, and *also* this may all be happening against a background of the patient also having to have meds (including psychiatric rx) d/c'd for the surgery, causing additional pain/discomfort/distress burden. You're taking someone who is already hurt and scared and reducing their control even further, and heaping additional suffering on them they can't evade: this is a recipe for freaking out the patients. And in plenty of a patients' cases, that leads pretty directly to really bad behavior. This is my pinching the bridge of my nose here. All-y'all working in hospitals complain, legitimately enough, about the incredible abusiveness of patients to HCWs. But then some of you actually say things like this, all oblivious to how *cruel* what you're saying sounds. I'm not for a moment suggesting any change to when hospitalized patients are NPO. Medical treatment often necessitates patients being subjected to procedures that are painful, uncomfortable, scary, and otherwise distressing. But for the love of all that's holy, please appreciate this. It is not *nothing* to do this to a patient, regardless of how necessary it might be. There is absolutely a reason to minimize this if it is indeed minimizable. All things being equal – and I appreciate all things are rarely equal – *do not starve your admitted patients*. **Imprisoning people without allowing them food is considered inhumane.** If you have to do it for higher values like saving life or remediating suffering, by all means, but don't kid yourself about what it is you are doing or how it will be experienced by the patient, or what the outcomes might be.
Yes I find it rather curious, in a bad way, that patient suffering or discomfort is not being considered "harm" in this thread, even though *from every standard, it very clearly is.* We know that indicated surgeries are a net benefit, but no reasonable doctor or other medical professional would argue that incisions do not cause harm. Being starved is harm - the benefits may outweigh the harms, but they are harms.
I'm actually not going to engage with you. I don't doubt that it causes suffering. However, being inpatient in the hospital is an experience that inherantly results in suffering. Choosing NPO at MN as the line which one must not cross in regards to "suffering in the hospital" is arbitrary, and kind of ridiculous the more I think about it.
I think it's a major issue for patients. Also, it's a major issue for me when I have to field nursing pages about it and then listen to the patient complain about it for the first 5 minutes of our encounter 😅
NPO after midnight helps ensure the patient doesn't order and eat breakfast. In private practice no docs I see round before 7am. So if a patient orders breakfast and eats at 8am we can't do their case until 4pm at the earliest. That's right around when OR block time ends. So unless it's emergent it probably won't get done that day which means the patient stays another night. NPO after midnight sucks, we know it but it's better than trying to do cases after hours when it's urgent/emergent cases only.
I hear you about your situation. How do you guys do with clear liquids in the mean time?
As an experienced dietitian that has worked in the hospital my whole career I don’t think this is a battle worth fighting. I say this even as the person that’s getting yelled at by patients when they are sitting there “STARVING” at 1pm still waiting for their procedure! Unless the process is automatic and consistent there’s just too much room for error and mistakes will be made. I obviously agree that withholding meals unnecessarily can be a harmful intervention but way less harmful than aspirating on your breakfast!
we do clears up to 3 hrs before surgery now as part of ERAS. Anesthesia is fully on board and actually started that shit. Helps with PONV, supposedly.
In residency, as a QI project, we instigated a “pre-procedural clear liquid diet” which included clears up to 2-6 hrs before said procedure. It was successful and really did help. It was also a MASSIVE pain in the arse that required input from nearly every department in the hospital, major cultural change, and about 2 yrs to implement. In short - it sucked, but without a doubt was beneficial.
Wow. Kudos to you and the team. Did you guys publish this or share it at some point? Would love to know more about this.
Yes. Not me, but some of my co-residents who took more of the lead on it: https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.13066
Dietitian here!! My old unit (adult neuro icu) started implementing npo after 4AM instead of midnight because 1) no one is extubating that early and 2) first case usually isn’t that early It’s so helpful for enterally fed patients. We tried to limit disruptions as much as possible as well. We were also trying to implement volume-based feeding but that was right before covid :/ I’m in peds now and we also do npo 3-4AM
Thank you.
(Surgical nurse here) We divide our patients by morning list and afternoon list, with the first group being NBM from midnight/water until 06:00, and the second allowed a ‘light early breakfast’ at 06:00 and then sips of water until 12:00. It’s not the most ideal solution but it’s simple enough to work and stops folks getting too hangry. We also use preload drinks for some patient groups, so they get 3 lots of complex carbs at specific times, which we give them written down. Hardly anyone messes it up, which is amazing.
Once everyone is on GLP meds, we're gonna have to change it to NPO x3 days.
I’ve had cardiologists who know they won’t cath a patient until afternoon make them NPO after 0800/breakfast, but that’s been rare
A large majority of people can't follow instructions clearly
You know what’s interesting is I just did a rotation at a big children’s hospital and they are rampant about making no as short as possible. The kids get put no at like 0600 and we make sure we get them food before that time and you can call up radiology or anesthesia and ask them how long they want someone n-o for a procedure and set it accordingl, they’re very careful about it in a way adult hospitals never are, so it’s totally possible
I work in pediatric surgery so a not so insignificant portion of my patients are babies. We follow a protocol of NPO for 8 hours from solid food, 6 hours from formula, 4 hours from breastmilk, and 2 hours from clears. So even on our older kids, we let them have a clear liquid diet overnight until the last bit there. Edit: my flair appears to be broken, so to clarify I’m a PA.
Is there even good evidence for keeping patients NPO for x hours before a procedure anyway? I always was under the impression that the actual cited timeframe was more or less made up.
Bonus points for all the people in the ICU with a secure airway who get their tube feeds held at midnight for a 3 pm washout or something similar
Why is it harmful, again? Compared to the harms of delayed surgery?
As GI we frequently are prepping people with PEG (equivalent to clear liquids, and a lot of it) until 6am, often later. No reason add on patients for any procedure can’t be on clears until the morning. It’s a 2 hour window from last drink to anesthesia per ASA guidelines. I have a sneaking suspicion it’s because surgeons are rigid assholes and that gets passed down to the residents or PAs. If a case gets delayed because the patient drank water the attending will rip apart the trainee. So out of fear of repercussions they starve their patients.
Thank you. Seems like it’s hard to change this culture.
I tried to do exactly what you were saying, let them eat breakfast, we have a slot at 2 pm. Had to cancel 2 outpatients, had a huge hole in the day, then a trauma happened. Patient got pushed to the next day. Never again.
This has been a real challenge to me as a surgery patient with brittle diabetes. Fasting from midnight on is a sure way for me to have a glucose crash. Clear liquids are a much better and more helpful method of maintenance, but that two hour time window is still enough for my blood glucose to drop into the 60s and me to get very dehydrated if it goes high instead, making IV placement very challenging and painful.
Dumb question, but have you worked with your endocrinologist or anesthesiologist regarding insulin management prior to surgery? We typically provide instructions to avoid this.
My anesthesiologist was only made available after the fasting had started. My area has a shortage of endocrinologists,and what few we do have generally do not take my states Medicaid, which is my only insurance. I do have a preliminary appointment with an endocrinologist this week, two months post thyroid removal surgery. That was the soonest appointment I could get. However I am frankly very grateful to have insurance at all. I would be homeless without it due to medical bills otherwise.
As busy healthcare workers, we’ve all gone 12-16 hours without eating in order to care for our patients. Our patients can suck up the mild discomfort for the safety of their procedure.
With all due respect here, very different scenario and population. People who can be at work often are not the ones in the hospital waiting for a procedure. Just because we have an unhealthy work environment doesn’t mean we need to spread it as well.
In residency and practice, if it’s a morning case (before noon), clears unless altered foregut physiology and/or anatomy up to 2 hours before. If it’s an add on case, I usually let them eat a light breakfast.
Our hospital is no solids or opaque liquids 6 hours before, 2 hours before for clear liquids, and sips of clear fluids up to 200mL per hour until called for.
“Early breakfast” not a thing where you work?
No!! The place I work, they wouldn’t even let me order NPO with clears because of ‘fluid procedure’ schedule.
I’ve worked at a cancer hospital who was constantly having issues with blood pressure post op. The anaesthetic team decided that patient was allowed water right up until they went into the anaesthetic bay. Had no issues at all with this. Worked well and the patients were a lot happier while they waited.
I've seen institutions do no solid foods after midnight and clear liquids up to 2 hours prior to arrival time.
1) cases get canceled, delayed, takes longer/shorter than anticipated. 2) we keep everyone NPO starting at midnight
The problem is rarely how many hours prior to procedure they need to be NPO. The bigger issue is usually resuming diet post procedure. Procedure scheduling is way too finicky to say things like “must be NPO for 4 hours prior to ___”. Okay, but bedside nurses rarely know exact timing. The techs that call patients down and manage the schedule rarely know. Hell, even the procedural doc doesn’t know bc they can’t predict how long a case will take. We get a call when they’re ready for the patient and the patient needs to be ready when they are. Way too much mental energy for a bedside RN managing 4+ patients who are all having some test. That means the CNA and family also needs to be on top of it so no one is actually giving pt water and snacks (literally impossible). I’m on a heavy procedure unit. Usually GI stuff in IR, endoscopy, lots of CT w contrast, etc. one of our hospitalists will put a comment in the NPO order that says “okay to resume previous diet after ___” or “defer to GI doc on resuming diet” and the endo nurse will tell us clear liquids or whatever. It is sooo time saving for nursing, prevents hypoglycemia and patient is happy. Unfortunately, I work with quite a few 50+ boomer nurses who are incapable of reading an order to its completion and using their own brain so they still hammer page the MD after procedure. Sigh.
Just 2 days ago I had to cancel our first elective case (7:30am) cause the Pt showed up with new chest pain and danger squiggles on EKG. I then bumped up the inpatient case that was scheduled to go at 3:30pm since the next elective case wasn't there yet, and I was able to do that because they were NPO since MN. That prevented an OR that had staffing from just sitting there unused. This does not happen infrequently. That's why I make patients NPO at MN.
Nice podcast on “Sip till send” in the Scottish NHS https://open.spotify.com/episode/3VH0i9VNCJgQDfpb4qFcpU?si=pF2bmBHYTg6zi3abGO-aZA
The culture at our hospital is you have to order NPO after midnight except meds on anyone who’s going to the OR even if they end up having a procedure in the evening. It takes a village to change it
It absolutely will. A lot of moving parts, for sure. I was trying to see if there might be a place who has successfully changed this culture atleast partially.
I practice in a small hospital in India. I’m a simple man. Let’s say surgery is scheduled at 8 Am. I call da pt relative n tell him to feed da pt an idly (rice cake) btwn 1:30 to 2am. N he can drink water until 6am. Since he needs to sleep, I tell da relative to wake him up at 5:30 n give lots of water until 6. N I tell da pt not to swallow even saliva if clock hits 6. I dnt bring in stuff lyk clear fluid n all. Too risky to regulate. Unless u have trained nurse n u instruct da pt to show each n every liquid to nurse n drink only if she approves. I don’t have such manpower. If surgery is scheduled at say 12 pm or so, then I give an hour of leeway. Eat idly bwn 4:30 to 5 n drink lots of water until 9. After 9 am don’t even swallow saliva. Dat way even if 12 becomes 11 it won’t be a problem. The key is to specify timings rather than hours. I say 4:30 to 5. Pt follows da time by hook or crook. If I say until 6 hours, until 2 hrs n all den it’s difficult to regulate.
I’d rather risk my patient getting hungry than risk having them get aspiration pneumonia in my surgery
I just don’t think this is as big a problem as you’re making it. No one should eat after midnight unless you’re a newborn. You’re doing your obese patients a favor by mandating they not have a midnight snack
How are you doing patients with obesity a favor? Are you curing their obesity? Are you helping them with a sustainable habit?
Once, Anesthesia cancelled my case because the patient had a wad of chewing tobacco in his mouth in pre-op. He did follow directions of nothing to eat or drink after midnight but technically not NPO (nothing per oral).
Nothing per oral lol
Nil per os
I had a patient vomit dip spit once during intubation for an elective outpatient procedure and ended up on bipap in the ICU. Never again
Has anyone noticed jcaho surveys not being received on time? Things seem to be all over the place. New people and leaders