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 evi dence 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