NPO for acute abdomens

[ZA_Gasman]

Was wondering about an issue that has just cropped up on my call. 58 y.old male for exploratory laparotomy for presumed appendicitis. Chap has just had 500ml of a maize type drink people drink over here - think a consistency like milk with floaty bits in it (not my cup of tea, but anyway).

So, the question is, in the absence of immediately life threatening intra-abd pathology, is it reasonable to wait for 6 hrs (or whatever your current preop starvation protocol dictates) or should one go ahead, since we are going to RSI the guy in any case as he has an acute abdomen. As a side note, I'm always amazed that people can tolerate food with an acute abdo. Obviously made of stronger stuff than I am.

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[militarymd]

go to sleep.

 

[VolatileAgent]

yeah, you don't wait. you have to go to sleep. if the patient has an acute abdomen truly, that stuff ain't going anywhere in 4-6 hours anyway. recently did an "acute abdomen" anesthetic on a patient who told me that she hadn't eaten anything in three days. after RSI, i put the NG in, and get back 600 ml of brown crap.

 

[blocks]

why not place an NG prior to RSI?

 

[VolatileAgent]

suppose you could, but then you've got a better conduit to the trachea (ie, you've left an opening there). and using sux, at least in theory, increases LES tone. so, if you have an NG in place, you've got an area where stomach contents can get around. and, try to pass a NG on an awake person. it isn't particularly easy or pleasant, and they might vomit while you try (although their upper airway reflexes will still be intact, granted). additionally, you could try bicitra as well, but this isn't going to do much on a stomach that's otherwise full. you shouldn't give reglan in an acute abdomen either. lastly, there's a lot of debate about how effective cricoid pressure actually is in RSI anyway. why further potentially compromise the airway with an extra tube into the place you're trying to avoid?

the bottom line is, you can't (and shouldn't) wait six hours. you go to sleep and try to best prepare for any possibility that may happen. then you put the NG in. and, of course you've asked beforehand if/when the last episode of vomiting was, if the patient is actively nauseous, and when the last time they had P.O. was as well. at least, that's how i'd do (and have done) it. so far, no disasters.

 

[Planktonmd]

Acute abdomen = go to sleep.
All our appendecitis patients get a CT scan with PO contrast about 45 minutes before surgery
Just remember to do a real RSI.

 

[jwk]

Most of our appy patients have a stomach full of X-Ray contrast anyway. Night night.

 

[VentdependenT]

why not place an NG prior to RSI?

You could. I don't think there is proof that this prevents aspiration however. Plus the patient can reflux crap from their small bowel right around the ngt and into your airway.

I don't believe anyone would falt you for placing an NGT prior to induction but you have to weigh the benifits (possible decrease in aspiration?) versus the risks (perfing something, pain, causing the patient to puke while putting the ngt in, shoving it in the lung, etc etc).

RSI if the airway permits baby.

 

[VolatileAgent]

RSI if the airway permits baby.

what else would be in your plan? (that's not a pimp question. i'm seriously asking. obese patients should be "presumed full stomach" patients, yet we don't do an rsi on all of them. we also don't do awake fiberoptics on all of them either. if you have an acute abdomen, you first attempt an rsi. period. if you can't get it, you wake them up and THEN try something else.)