Clinical Audit on Nil Per Oral (NPO) Timings: Optimizing Patient Outcomes and Satisfaction

Clinical audit on Nil per Oral (NPO)

“Not less/Not More”

N S. Sushmithaa

Final year anaesthesia PG, Kauvery Hospital, Cantonment, Trichy

Abstract

Aim

To reduce prolonged fasting or inadequate fasting prior to Anaesthesia by proper patient education and care, thereby preventing its complications.

Purpose of the audit

Fasting before general anesthesia aims to reduce the volume and acidity of stomach contents, which reduces the risk of regurgitation and aspiration.

However, unnecessary prolonged fasting periods might result in thirst and hunger before surgery which decreases patient satisfaction and increases the risk of post induction hypotension. Therefore, maintaining proper Nil Per Oral timings play a major role in improving patient outcome before , during and after surgery.

Materials

Place of audit: KMC Speciality Hospital, Cantonment
Date of audit: July 2022 to January 2023.
Source of audit: Operation Theatre, KMC speciality hospital, Cantonment
Done by: Department of Anaesthesiology

Methodology

All patients undergoing elective surgery under Anaesthesia.

Demographic details of patient

Diagnosis and proposed surgery

Duration of fasting – type of meal: heavy meal, semi solid and clear liquid.

General physical condition, urine output, IV fluid infusion value, vasopressor usage.

Traditional practice

Results for the data of 2022(October to December)

Total Cases – 914

Problems identified

Improper patient education
Inadequate knowledge among paramedical staff
Unexpected delay in surgery
Addition of emergency cases
Communication error

Observation

A 35% of the population had complications associated with prolonged fasting.

Patient with prolonged fasting develop,

Anxiety
Drowsy
Pre-operative and intra-operative thirst
De-hydration
Hemodynamic alteration – tachycardia and hypotension
Metabolic alterations

Updates from recent journals

There is growing evidence that more liberal clear fluid intake might not increase the risk of pulmonary aspiration.
Recent studies and researches encourage clear fluids Upto 1 hour before elective general anaesthesia.
One study was undertaken with 150 ml of water 2 hours prior to surgery vs overnight fasting usual practice
Patients who consumed 150 ml water 2 hours prior to the procedure had gastric pH and volume unaffected whereas in patients with prolonged fasting there was an decrease in gastric pH and increase in volume.

NPO After midnight – Blanket fasting policy

Recommended ASA Guidelines

8 hr – Fatty and oily foods
6 hr – Solids
4 hr -Semisolids,breast milk
2 hr – Liquids

Corrections implemented

1. Improper patient education

Detailed explanation and counselling during Pre-operative assessment
Most of the time patient don’t know what kind of food comes under semi solids and liquids
So we gave them a printed chart regarding foods which they can consume will give a clear idea to patients
All patients were given 150 ml of tender coconut water 2 hours prior to the procedure

What can they have?

Solids	8 hr	Regular meals Breakfast
Semisolids	6 hr	Pulpy juices Tender coconut Milk products
Liquids	2 hr	Clear water Filtered juice Tender coconut water

2. Unexpected delay in surgery

3. Addition of Emergency cases

4. Communication error

One solution for all these problems was,

We appointed a physician assistant to look for the new added cases and delayed cases everyday routinely in the morning and accordingly communicate with the corresponding ward staffs and patients.

We encouraged adequate intake of clear water and filtered juices during the time of delay so that NPO status could also be maintained with patients comfort and satisfaction.

How we managed the surgery time changes

Not advised to take following drinks 2 hr prior to surgery

Energy drinks
Coconut water
Lemon pulp

Results for the Data of 2023 (January to March)

Total Cases – 100

Observation

Only 9% of the population exceeded the standard NPO timeline
Patient satisfaction and comfort was improved
Dehydration, Thirst, anxiety, hypotension was minimised after these measures
Hemodynamic stability was much better intra operatively
Post-operative wound healing was also much better and early recovery could be achieved.

Comparison of Both the Data’s

Parameters	2022 (%)	2023(%)
Patient discomfort	56	11
Hypotension	18	15
Dehydration	18	13
Post op nausea	7	6

Conclusion

Hence,

Proper education
Proper communication
Proper follow up

Helped in improving patient satisfaction and minimising intra operative complications due to prolonged fasting.

Dr. N S Sushmithaa
Final year DNB Anaesthesiology

Clinical audit on Nil per Oral (NPO)