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October 22, 2016
10/22/2016 10:00:00 AM - 10/22/2016 12:00:00 PM
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To Eat or Not to Eat: Examining Adherence to ASA NPO Guidelines Among Michigan Hospitals
Mallika S. Thampy, M.D., Hussein A. Issa, M.D., Michael L. Schostak, M.D., Roy G. Soto, M.D.
William Beaumont Hospital, Royal Oak, Michigan, United States
Disclosures:  M.S. Thampy: None. H.A. Issa: None. M.L. Schostak: None. R.G. Soto: F. Funded Research; Self; Merck Pharmaceuticals, Schering Plough Pharmaceuticals, Organon Pharmaceuticals.
1) Background

Preoperative fasting is recommended for all patients undergoing elective surgery. This classic dictum requires abstinence from oral intake for a defined interval prior to the operation. Nihil per os, or "NPO" is recognized as effective for preventing pulmonary aspiration from the gastrointestinal tract while the patient undergoes an anesthetic. NPO guidelines have changed over the history of anesthesia and elective surgery. Prior to 1960, textbooks suggested 2-3 hours for clear liquids and 4-6 hours for a light meal. This is consistent with the knowledge that clear liquids are emptied more quickly than solids. In the 1960s, without introduction of new evidence, most American anesthesiology textbooks recommended a change to NPO after midnight. However, in 1999, evidence-based guidelines for pre-operative fasting were published by the American Society of Anesthesiologists (ASA): 2 hours for clear liquids; 4 hours for breast milk; 6 hours for a light meal; and 8 hours for unrestricted intake. Despite these guidelines, many centers still adhere to out-dated protocols. We designed this study to determine the incidence of compliance with the 1999 guidelines.

2) Methods:

Over a 3 month period, Michigan Hospital Association hospitals & surgical ambulatory care centers were contacted and surveyed regarding preoperative fasting guidelines. Fasting guidelines for liquids and solids were documented and institutions were divided into 2 groups: those which were compliant with, and those which were not compliant with ASA guidelines. Responses from those not compliant were further divided into sub groups for analysis.

3) Results:

100 percent of hospitals contacted stated that they adhered to a defined NPO policy. 25% complied with the aforementioned 1999 ASA guidelines. Of those which were noncompliant, 22% had a strict NPO after midnight policy, 15% made exceptions for patients with specific comorbidities, and 38% had a policy allowing liquids at a more conservative fasting interval.

4) Conclusions:

Evidence-based guidelines for preoperative fasting have been well-described in anesthesia literature for over 15 years. Despite clear benefits of preoperative hydration, the majority of surveyed surgical centers reported adherence to policies that were neither evidence-based nor compliant with ASA guidelines. As enhanced recovery protocols and the Peri-Operative Surgical Home enter the mainstream, attention must be given to patient prehabilitation. Preoperative nutrition, hydration, and carbohydrate loading are key components to appropriate patient preparation for good outcomes. As our results demonstrate, significant variability exists regarding NPO policies. Although we recognize the many administrative barriers to implementation, we recommend that all surgical patients undergoing elective procedures be allowed oral intake as outlined by the ASA.​

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