Pro/Con Debate: NPO vs. Non-NPO for light sedation cases Iosifina - - PowerPoint PPT Presentation

Pro/Con Debate: NPO vs. Non-NPO for light sedation cases

Iosifina Giannakikou, MD, MBBS. Anesthesia & Critical Care Medicine Hygeia Hospital, Athens, Greece

Contents

• Aspiration risk
• NPO guidelines
• Evidence
• Conclusion

• Incidence 66/44,016 (0.15%)
• Used ether inhalational anesthetic
• Not intubated
• Mendelson. Am J Obstet Gynecol.1946;52:191-205

• Non-obstetric adult population at a tertiary university center
• Incidence of perioperative pulmonary aspiration: 1/7,103 (0.01%)
• Mortality: 1/99,441 (0.001%)
• Sakai. Anesth Analg. 2006;103(4):941-7.

Anesthesiology 2017;126:376-393

• Patients included:
• Healthy patients
• All ages
• Elective procedures
• Procedures in which upper airway reflexes may be impaired

Anesthesiology 2017;126:376-393

Anesthesiology 2017;126:376-393

• 2 hours for liquids (may include tea or coffee with 20% milk)
• 6 hours for solid food

Eur J Anaesthesiol 2011;28:556-569

• Pulmonary aspiration: 1/10,000 GA (0.01%)
• Incidence of anesthesia associated fatal aspiration: 1/350,000

(0.0002%)

• Robinson. bjaceaccp 2014;4:4(171-175)

• Clear fluid (400ml) of carbohydrates
• 2 hours before anesthesia
• Pre-op:
• thirst, hunger, anxiety
• Post-op:
• nitrogen & protein loss
• insulin resistance
• Maintain lean body mass & muscle strength
• Gustafsson. World J Surg 2013; 3:(259-284)

• Pre-operative carbohydrate loading:
• No in pulmonary aspiration
• length of stay
• surgical complications
• Fawcett. BJA Education,17 (9) 2017:312-316

• 22 RCTs
• Allowed to drink up to 2 hrs pre-op vs fasting
• No difference in gastric content or pH
• No difference in complications
• Brady. Cochrane Database Syst Rev. 2003;(4)

• Systematic review of 25 RCT
• 2543 children
• Allowed to drink up to 2 hrs pre-op vs fasting
• No difference in gastric volume or pH
• Children allowed to drink were more comfortable and better

behaved than those starved

• Brady. The Cochrane database of systematic reviews. 2000

• 10,015 elective pediatric procedures under GA
• Drink clear fluids until called to OR
• Aspiration 3/10,015 (0.03%)
• No cancellations/ICU/vent support/deaths
• Andersson. Pediatric Anaesthesia. 2015; 25(8):770-777

• 139,142 pediatric procedural sedations
• 25,401 patients NOT NPO
• Aspirations: 10/139,142 (0.0072%)
• No difference in aspiration/ major complications
• Beach. Anesthesiology.2016;124:80-88

• 2085 pediatric procedural sedations
• 1555 cases with documented fasting times
• Fasting: <2hrs, 2-4 hrs, 4-6hrs, 6-8 hrs, >8hrs
• No clinical apparent aspiration
• Same incidence of adverse events
• Roback. Ann Emerg Med. 2004;44(5):454-9.

• Prospective observational study
• 400 adult & pediatric procedural sedations
• 71% NOT meet ASA fasting guidelines
• No difference in adverse events
• Vomiting: fasted 0.4%, non-fasted 0.8%
• Bell. EMA. 2007;19(5):405-10

• Systematic review
• 4657 adults + 17672 pediatrics
• No association between fasting time and adverse events
• Thorpe. EMJ.2010;27(4):254-61.

• Prospective observational study
• 2623 patients
• 1 (0.05%) aspiration event (in a fasted patient)
• No association between time of last oral intake and vomiting
• Taylor. EMA. 2011;23(4):466-73

• Multicenter prospective cohort study
• 6183 pediatric sedations
• >50% not fasted
• No cases of aspiration
• No association between time spent fasting and adverse events,

vomiting

• Bhatt. JAMA Pediatr. 2018;172(7):678-685

• Do not delay procedural sedation in adults or pediatrics in the ED

based on fasting time. Pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (Level B)

• Godwin. Ann Emerg Med.2014;63:247-258

• 228 patients ASA I &II
• Non-fasting had

complications than fasting pts

• Minimal-to-moderate sedation

in non fasting patients is safe

• Besi. Oral Surgery 11(2018)98-104

• “The literature does not provide sufficient evidence to test the

hypothesis that pre-procedure fasting results in a decreased incidence of adverse outcomes in patients undergoing either moderate or deep sedation”

• Anesthesiology. 2002;96(4):1004-17

• Retrospective review
• 5125 pts having cataract surgery
• No pre-op fasting
• Topical/infiltration anesthesia with iv sedation
• NO aspiration pneumonia found
• Fasting NOT required prior to cataract surgery
• Sanmugasunderam. Can J Ophthalmol. 2009;44(6):655-6

• 25% of Michigan hospitals adhered to ASA NPO guidelines
• Thampy. ASA annual meeting 2016, abstract A1024

• The “Nothing after midnight” fasting rule is “easier”
• Fear of litigation in case of aspiration
• More flexibility of schedule
• Kamenev. Medical examiner. Slate.2017

• Very small risk of aspiration in sedation cases
• Same aspiration risk in fasted and non-fasted pts
• No effect on other adverse events inc. vomiting
• Higher patient satisfaction