SAMBA Talks eNewsletter - July, 2006

Volume 6, Issue 2

S A M B A T A L K S - PAGE 2

July, 2006

JOIN THE DISCUSSION - TOP

Need advice about a problem case in ambulatory anesthesia? Want suggestions about a difficult situation in your ambulatory surgery center? Have a reply to questions others have raised about ambulatory anesthesia issues?

If you answered "yes" to any of these questions, or would like to share with other professionals a comment or opinion on a topic related to ambulatory anesthesia then please "Join the Discussion" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your submission will be published in this section of the next available issue of SAMBA TALKS. Include your name (or initials), city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before the questions can be published.

Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

Please note: The information presented in the replies below does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTION WITH REPLIES - ?? - TOP

At my Surgicenter gastroentrologists bring patients for EGD and colonoscopy. These patients are sipping water until they enter Surgicenter. We do not do these patients for 3 - 4 hours after last drink. Gastroenterologists claim that they used to do these cases before without anesthesia and they never found water in the stomach. What is your opinion on NPO status for EGD and colonoscopies?

-- Mahendra Shah, MD, Trenton, NJ

Answer 1

As practicing anesthesiologists we have a responsibility to deliver the safest possible care in accordance with accepted practice parameters. The American Society of Anesthesiologists issued Practice Guidelines for Preoperative Fasting in 1999, which we all must heed (1). These guidelines were to reduce the risk of pulmonary aspiration but they do not “guarantee complete gastric emptying”.

In adults, the recommended time for fasting from clear liquids was 2 hours. A light meal required a minimum fasting time of 6 hours. These were for healthy patients and did not include women in labor, or patients who had presumed gastric pathology. If you follow the ASA guidelines, as you have been doing, then you are practicing within the parameters set out by your fellow professionals and will be less open to criticism if an untoward event occurs.

At our cancer institution the suggested minimum (adult) fasting time is 4 hours for clear liquids and 8 hours for solid food but our patients are not considered “healthy”. I do try to ensure that patients understand that the period of fasting is to protect them from a major pulmonary event rather than to prevent nausea or something similar. If a patient does not follow our “rules” they may be testing our limits. Many years ago a patient who had admitted only to a “sip of milk” was delayed and given a rapid sequence induction eight hours later. The initial few milligrams of sodium pentothal resulted in a confession of “cake” intake and a request to “not die”. The case was cancelled.

-- Peter H Norman, MD. Houston, TX

(1) Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures. Anesthesiology 1999; 90: 896-905

See: http://www.asahq.org/publicationsAndServices/NPO.pdf

Answer 2

The 1999 ASA guidelines provide fairly straightforward guidance on this issue. At least two hours should elapse between the consumption of clear fluids and the administration of anesthesia. Why are the patients sipping water? Do the gastroenterologists believe there is some actual benefit to this practice?

Although guidelines are never the final word on clinical decision-making, allowing your patients to drink right up to the moment of the procedure seems unwise. Despite the fact that the ASA guidelines have not been updated since their publication, they remain the most definitive, evidence-based statement of our national society and one would have to offer pretty strong alternate evidence to support a different approach, especially if aspiration or some other mishap to were to occur during a procedure.

-- Gary Kantor, MD, Cleveland, OH

?? -- THIS MONTH'S QUESTION -- ?? - TOP

For an EGD/colonoscopy what is considered a safe or unsafe BMI for patients that have no other health concerns, and also for patients that have other factors to consider. We are an ambulatory surgical center constantly being faced with weight factors. I am trying to set some sort of guideline for the office to follow when scheduling these procedures. I would appreciate any input available.

-- Susan, Ft Myers, FL.

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