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Cleveland Clinic Journal of MedicineDoes My Hospitalized Patient Need an NPO-After-Midnight Order Preoperatively?

Rethinking Preoperative Fasting: Evolving Practices and Emerging Evidence

The traditional practice of ordering “nothing by mouth” (NPO) after midnight for patients awaiting surgery, particularly under general anesthesia, is being increasingly scrutinized in light of recent guidelines and studies. This article examines the implications of prolonged preoperative fasting, its historical basis, and the shift towards more patient-centered, evidence-based approaches. It emphasizes the need for a balanced approach to preoperative fasting that prioritizes patient safety, comfort, and current medical guidelines.

Key Points:

  • Historical Practice: NPO after midnight has been a common preoperative instruction to mitigate aspiration risk during general anesthesia.
  • Patient Impact: Extended fasting can cause patient discomfort, dehydration, and dissatisfaction, often without improving surgical outcomes.
  • Guideline Shifts: The American Society of Anesthesiologists and the European Society of Anaesthesiology recommend lighter fasting protocols — clear liquids up to 2 hours and light meals up to 6 hours before anesthesia.
  • Unnecessary Prolongation: Lengthy fasting periods are frequently more about scheduling convenience than patient welfare.
  • Evidence Against Prolonged Fasting: Studies show that shorter fasting does not increase aspiration risk or surgical cancellations.
  • High-Risk Patients: Extended fasting may still be necessary for patients at high risk of aspiration, such as those with obesity or a history of esophageal surgery.
  • Institutional Protocols: Hospitals are encouraged to adopt multidisciplinary protocols based on current guidelines for elective and semi-urgent procedures.
  • Patient-Centered Approach: Tailoring NPO orders to individual patient needs can improve satisfaction and reduce hospital stay length.
  • Implementation Challenges: Widespread adoption of updated guidelines is slow, partly due to ingrained practices and lack of communication among medical staff.

The American Society of Anesthesiologists (ASA) guidelines for preoperative fasting allow light meals up to 6 hours and clear liquids up to 2 hours before elective procedures utilizing general anesthesia.

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