NPO Guidelines

Kramer and Bennet

Introduction

- NPO guideline initially given to reduce postoperative nausea and vomiting

- There is no evidence that pediatric patients with prolonged preoperative fasting period of >6
hours when compared to those receiving unlimited clear liquids up to 2 hours preoperatively
- Patients with clear liquids up to 2 hours pre-operatively had lower gastric volume vs the 6 hr
NPO group

Clear Liquids

- Clear liquids up to 2 hours NPO are beneficial due to their quick emptying halftime (10-20
minutes) due to pressure gradient b/w stomach and duodenum
- Clear liquids are cleared within 2 hours
o Clear liquids = water, carbonated beverages, fruit cjuice, black coffee or tea
- ASA does not discuss allowable volume of clear liquids,
- Preoperative oral medications can be taken with minimal water, NOT violation of NPO status

Breast milk and infant formula

- Breast milk allowed up to 4 hours pre-operatively

- Formula held for 6 hours

Solid foods and nonhuman milk

- Animal milk is considered a solid because it congeals into a semi-solid mass in the stomach
- ASA suggests solid foods should be withheld 6 hours prior to surgery, with lighter meals
recommended closer to the 6 hour mark
- Clearance of solid food greatly varies and is dependent on quantity, and type of food and size of
ingested particles.
- >2mm particles pass in a linear manner
- Pyloric sphincter prevents solids larger? than 2mm to pass from stomach
- Breakdown of larger particles to pass the pyloric sphincter may take up to 4 hours
- Fatty foods (eggs, bacon etc) take up to 8 hours to clear, NPO 8+ hours
- Light breakfast (plain toast, black coffee) = NPO 6 hrs
- Once all particles that are <2mm are digested and passed through, the non-digestible materials
are passed through (funnel effect)

Preoperative therapeutics

- Antacids, PPIs, H2 blockers show little therapeutic benefit prior to intubation and preventing
aspiration
- Cricoid pressure shown to prevent aspiration but only reserved for intubation

Antacids

- Theorized to be used preoperatively to neutralize pH of gastric contents

 o Historically used aluminum or magnesium hydroxide (inhsoluble particulate) or soluble
nonparticulate (sodium citrate or sodium bicarbonate)
o Particulates if aspirated into lungs can cause inflammation and tissue damage equal to
gastric fluid aspiration (no longer encouraged)
- Nonparticulate antacids recommended because ease of mixing with gastric fluid
- Preoperative antacids (sodium citrate) only recommended in patients with increased risk for
aspiration

Gastric Pryokinetics

- Gastric prokinetics are given to aid with gastric emptying by increasing gastric motility
o Metoclopramide is used (Dopamine antagonist) which stimulates gastric motility and
empties residual gastric contents
o Metoclopramide given 15-30 minutes prior to induction
- Complications of metoclopramide = akathisia, oculogyric crisis, muscle spasms, and other
extrapyramidal effects
o Include involuntary muscle contraction, tremors, stiff muscles, and involuntary facial
movements
- GI stimulants are contraindicated in patients with bowel obstruction or risk of cramping
- Metoclopramide only indicated in patients with increased risk of aspiration and regurgitation
and is not recommended in routine low risk patients

PPIs and H2 blockers

- PPIs inhibit H+/K+-dependent ATPase proton pumps in gastric parietal cells

- H2 blockers are reversible competitive antagonists that work on parietal cells H2 receptors
- Both PPIs and H2 blockers result in a decreased secretion in HCl, causing increase in gastric pH
- PPI/H2 use for GERD should be continued through perioperative period
- Elective PPI/H2 use can be used for higher risk patients, not recommended for routine low risk
patients

Cricoid Pressure

- Sellick Maneuver 1961

- Preventing reflux of gastric contents by applying posterior pressure on cricoid cartilage to seal
off esophagus
- Applied until successful intubation is complete
- Pressure = 30-40N (3-4 kg)

Summary

- Current NPO guidelines designed to specifically prevent regurgitation and pulmonary aspiration