Acute Care Surgery Pre-Operative NPO Protocol

Original Date: 03/2014 | Supersedes: 08/2017, 06/2021 | Last Review Date: 04/2024
Purpose: To safely minimize the amount of perioperative fasting in critically injured trauma patients.

This protocol applies to patients scheduled to go to the operating room or interventional radiology suite for a planned procedure.

Patients with a secured airway with a cuff (e.g. endotracheal tube, tracheostomy)

  • When receiving gastric enteral feeds:
    • The bedside nurse is to make the patient nothing per os (NPO) once the patient is called for the operating
    • There will be no automatic NPO status after
    • At the time the patient is called for the operating room, the bedside nurse will suction the stomach unless no orogastric/nasogastric tube (OGT/ NGT) is present, in which case an OGT will be inserted for this purpose (inserted intra-operatively by anesthesiologist).
    • The volume of suctioned content is to be recorded in Care4 in the output section and based off of the volume recorded in the anesthesia record/handoff form.
    • Common surgeries that should be NPO (this list is not intended to include all possibilities):
      • Tracheostomy (or other procedures/surgeries involving the airway including tube changes)
      • Patients undergoing procedures necessitating prone positioning such as:
        • Posterior cervical spine
        • Thoracic, lumbar spine
        • Sacral procedures
      • Video-assisted thoracoscopic surgery (VATS)
      • Face and neck surgery
      • Gastrostomy and jejunostomy
      • If concerns are specifically raised by the OR (Anesthesiology or Surgery) team and documented preoperatively
    • Common surgeries that should not be NPO (this list is not intended to include all possibilities):
      • Rib plating
      • Abdominal washout
      • Orthopedic extremity procedures
      • Plastic and/or reconstructive surgery on the extremities
  • When receiving post-pyloric* enteral feeds
    • Post-pyloric enteral feeds will be discontinued once the patient is called for the operating room
    • There will be no automatic NPO status after midnight regardless of airway status
    • *For patients with an unprotected airway, post-pyloric tube placement should be confirmed within 48 hours of procedure
  • Patients without a secured airway with a cuff (e.g. not intubated, uncuffed tracheostomy):
    • When receiving per os (PO) feeds
      • MD orders clear liquid diet after midnight
      • Bedside RN stops clear liquid diet 3 hours before the posted surgical time
      • MD resumes previous diet after procedures
    • When receiving gastric enteral feeds
      • MD orders NPO after midnight
      • Resume enteral nutrition at previous rate after procedures
    • When receiving post-pyloric enteral feeds
      • Post-pyloric enteral feeds will be discontinued once the patient is called for the operating room
      • There will be no automatic NPO status after midnight regardless of airway status
    • When NPO due to non-functional GI tract or other appropriate reasons
      • Continue NPO order

Pre-operative NPO Protocol Flowsheet

Pre-operative-NPO-Protocol-Flowsheet

 

References

  1. Crenshaw JT, Winslow EH. Preoperative fasting: old habits die hard. Am J Nurs.2002 May;102(5):36-44
  2. Brady, M., Kinn, S., & Stuart, P. (2003). Preoperative fasting for adults to prevent perioperative complications. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.:CD004423
  3. Pandit, S.K., Loberg, K.W., & Pandit, U.A. (2000). Toast and tea before elective surgery? A national survey on current practice. Anesthesia & Analgesia, 90, 1348-1351
  4. McKinley AC, James RL, Mims GR 3rd. NPO after midnight before elective surgery is no longer common practice for the majority of anesthesiologists. Am J Anesthesiol. 1995 Mar-Apr; 22(2):88-92
  5. Scarlett M, Crawford-Sykes A, Nelson M. Preoperative starvation and pulmonary aspiration. New perspective and guidelines. West Indian Med J. 2002 Dec; 51(4):241-5
  6. Change in “npo” policy reveals safety and increased caloric intake of enteral feedings at a level one trauma center. M McCunn, A Linton, S Clifton, TM Scalea, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore
  7. Lee, J.C., Williams, G.W., Kozar, R.A., Kao, L.S., Mueck, K.M., Emerald, A.D., Villegas, N.C., Moore, L.J. Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit. J Parenter Enteral Nutr.