Burn and Trauma Anesthesia: Thinking Outside the NPO Guideline Box

ASA has developed practice guidelines for preoperative fasting, most recently updated in 2017, with the goal of reducing the risk of pulmonary aspiration for healthy patients undergoing elective procedures.  These current ASA “Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration” are well defined and remain essentially unchanged over the years. Many medical centers across the country strictly adhere to these practice guidelines for all cases, including the critically ill and critically injured, encompassing trauma and burns. They advise that a critically ill patient is at an increased risk of regurgitation and pulmonary aspiration, even if the practice guidelines are followed. However, one must weigh the risk of aspiration versus the need for high caloric input that burned and critically ill patients require. Studies over the past 20 years have shown the need for proper nutrition for ideal healing, which is best when given enterally. It is often difficult to stop the perioperative fasting dogma of the past, and patients are often made NPO at midnight, regardless of their surgery time the next day. Following these guidelines, patients with enteral tube feeds often have their nutrition held for six hours or longer prior to surgery because the start time can be unpredictable. Additionally, critically ill patients often require multiple trips to the O.R., leading to frequent periods of time with inadequate enteral intake. By following the elective surgery protocols, patients can be NPO for a large part of each day that a surgery is performed. In addition, once a patient has completed surgery, there may be a several-hour delay to restarting enteral feeding due to recovery times either in the ICU or PACU. The goal of modifying this protocol is to safely increase the time a critically ill patient is receiving enteral nutrition in order to maximize his or her healing potential.