Everybody Eats! NPO Status in the Emergency Department

OVERVIEW

Food is routinely withheld from patients entering the emergency department in order to prevent the theoretical risk of aspiration should they require operative intervention or procedural sedation. This practice is not evidence-based and does more harm than good.

DISCUSSION

What is your practice for allowing, or prohibiting, people from eating in the emergency department?

• The risk of aspiration is low but not zero
  • Solids can occlude the airway
    • The case series on fatal aspirations that lead to the original NPO recommendations were all related to solid foods
  • Acidic contents can cause a pneumonitis
  • In the case of CT scans, the risk is essentially zero
  • In procedural sedation, only a handful of cases of fatal aspiration have been reported, almost all from endoscopy
  • In surgical retrospectives, the numbers are small, <1:1000. The amount of gastric contents required is also pretty high.
• Prolonged fasting does not actually reduce the amount of gastric contents when compared to shorter periods of fasting
  • Liquids will empty within about 90 minutes in most patients, even substantial amounts (1L)
• There is the potential for harm
  • Withholding food prompts a catabolic state and insulin resistance, delays healing, results in hypovolemia, and increases patient discomfort
• The relevant guidelines tend to be much more lenient than what we see in clinical practice
  • ERAS: Elective GI surgery - solid food 6 hours before, carb containing liquids 2 hours before
  • AAS: Fatty foods 8 hours/light meal 6 hours/carb containing fluids 2 hours
  • ERAS: Emergency laparotomy: In this very sick patient population (overall 10% mortality) there is a low level of evidence recommendation against liquid carb load 2-4 hours before surgery (which is recommended in the other guidelines)
    • On a case by case basis NGT decompression can be considered
    • If you think your patient has a surgical abdomen requiring emergent ex-lap NPO is not unreasonable. This is NOT most patients!
  • ACEP Procedural Sedation: Fasting guidelines have no supporting evidence, concerns exceed risk. Can consider delaying sedation in certain patient populations (obesity (though ERAS guidelines question this as a risk factor), gastroparesis (may want to consider GLP-1 use here), SBO (not feeding an SBO seems reasonable), or if the procedure is an endoscopy)
    • If delay from last oral intake is not feasible, ketamine is the preferred agent
  • Patients who will undergo an emergent class I laparotomy do not want to eat or if they have eaten their need for surgery will supercede this risk factor. Also, NGT decompression remains an option (for anesthesia to consider, not us)
  • Everyone else can likely have some kind of PO intake
    • Ginger ale is safe in almost everyone else until 2 hours pre-op
    • Light meals are probably fine in most people
    • Can consider holding the fried food if you are really concerned

TAKE-HOME POINTS

• The concern for aspiration exceeds the documented risk.
• If the patient would tolerate PO intake, they are probably 2-6 hours from any operative intervention anyway and can likely still eat even if headed to the OR. They can at least have carb-containing liquids, which has been shown to improve recovery.
• The risk of aspiration during procedural sedation is trivially low in most patients. Consider h/o gastroparesis, use of GLP-1 agonists, current SBO, and endoscopy as potential risk factors for clinically significant aspiration.
• Patients should be PO until proven otherwise!

References

1. Peden CJ, Aggarwal G, Aitken RJ, et al. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg. 2021;45(5): 1272–1290.
2. Feldheiser A, Aziz O, Baldini G, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, Part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2015;60(3):289–334.
3. Scott MJ, Baldini G, Fearon KCH, Feldheiser A, Feldman LS, Gan TJ, Ljungqvist O, Lobo DN, Rockall TA, Schricker T, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015.
4. Maltby JR. Fasting from midnight – the history behind the dogma. Best Pract Res Clin Anaesthesiol. 2006;20(3):363-378.
5. No authors listed. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. 2017; 126(3):376–393.
6. Green SM, Roback MG, Krauss BS, et al. Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019;73(5):e51 - e65.
7. Lee BY, Ok JJ, Abdelaziz Elsayed AA, Kim Y, Han DH. Preparative fasting for contrast-enhanced CT: reconsideration. Radiology. 2012;263(2):444-450.
8. Alkabbani W, Suissa K, Gu K D, Cromer S J, Paik J M, Bykov K et al. Glucagon-like peptide-1 receptor agonists before upper gastrointestinal endoscopy and risk of pulmonary aspiration or discontinuation of procedure: cohort study. BMJ. 2024;387:e080340.
9. Chang MG, Ripoll JG, Lopez E, Krishnan K, Bittner EA. A Scoping Review of GLP-1 Receptor Agonists: Are They Associated with Increased Gastric Contents, Regurgitation, and Aspiration Events? J Clin Med. 2024;13(21):6336. 
10. Anazco D, Fansa S, Hurtado MD, Camilleri M, Acosta A. Low Incidence of Pulmonary Aspiration During Upper Endoscopy in Patients Prescribed a Glucagon-Like Peptide 1 Receptor Agonist. Clin Gastroenterol Hepatol. 2024;22(6):1333-1335.e2.
11. Gioe B, Gioe S. S880: Risk of Aspiration for Patients on GLP-1 Agonists Undergoing EGD. Am J Gastroent. 2024;119(10S):S611.