Update Course Rewind: NPO Guidelines 2022

There is nothing to shake up an OR schedule rather than a patient who ate two hours before their scheduled operation. But is the risk of aspiration real? How long do patients really need to fast before an operation? Lucky for us, Dr. Mary Edwards, bring us up to speed on the latest data-driven recommendations. You are called at midnight from a community hospital with a level two NICU regarding your patient who is a 28-week preemie, who is scheduled for hernia repair at 7:00 in the morning. He's otherwise well and he's actually ready to go home, but the NICU has attempted to get an IV in him 10 times without success and they've had it and the kid has had it. They call you and they want to know what to do. You might say you should transfer that patient, but again, I think that the evidence I know our anesthesiologist allow P light up to even an hour or two hours before the procedure. So there's no reason you can't continue with oral hydration with a baby like this prior to surgery. This subject is evolving and it is amazing to me how variable practices are around the world. But I can briefly say NPO guidelines for children are in general based on very poor evidence and if you do even a Google search, you'll find that from institution to institution, they vary a lot. The outcomes following aspiration can be severe, but it's a relatively rare event in elective surgery populations. High risk patients are really those that are coming in for emergency procedures. And the other thing is studies suggest that clear liquids containing carbohydrates empty the stomach very quickly and that really doesn't vary based on age. One of the more recent consensus statements came out of Britain and Ireland and they essentially recommend one hour of NPO for clear liquids, four hours for breast milk, and six hours for solid foods in children under 17 years old. In the United States, the American Society of Anesthesiologists is updating their policy or their consensus statement on NPO guidelines. Currently what they recommend is two hours for clear liquids, four hours for breast milk, six hours for non-human milk and light meals and eight hours for a heavy meal. The European Society of Anesthesia and Intensive Care is even more liberal than that. They recommend only one hour of NPO for clear liquids, three hours for breast milk, four hours for formula, and six hours for all of their intake. These guidelines are those that are widely accepted in Australia and New Zealand as well. So things are moving in the direction of being more liberal. But I can tell you one thing about all these consensus statements is that there's now language in there that essentially says, you need to make every effort not to keep these children NPO for long periods of time prior to surgery. It's bad. It generates ketone bodies, causes hypoglycemia. It makes them just very irritable in the pre-op area. It's interesting, it's kind of aggravating that everyone does it different because it's confusing, but on the other hand, now maybe we can look at the differences and study that and see who does it better. Thanks for joining Dr. Edwards along with the rest of the AP Professional Development Committee for this update course rewind. And remember to check out the stay current app for more content related to pediatric surgery and more.