Drinking As Much As You Want Before Surgery Can Decrease PONV.

The American Society of Anesthesiologists has very clear guidelines for deciding when patients should stop any oral intake before surgery. These guidelines were made to prevent patients from aspirating gastric contents upon induction of anesthesia. For years, the rules were no solid foods up until six hours before surgery and no clear liquids two hours before the procedure.

Granted there have always been complaints from patients about how miserable they feel by the time they get to preop from having to fast for such a long period of time. It's especially bad for patients whose procedures take place in the afternoon and were given instructions to be NPO after midnight. Since this is by no means settled science, there is ongoing research to help remedy the situation.

Some have advocated letting patients drink carbohydrate rich fluids to help with the hypoglycemia that makes the patients feel so deprived. However, they still say nothing by mouth for two hours before surgery. Now the British have done something even more bold than Brexit--all you can drink right up to going into the operating room itself.

In a followup to a study first published in the European Journal of Anesthesiology in 2017, researchers in the UK allowed patients to drink as much as they want immediately before surgery. Covering over 30,000 patients, the study showed that the rates of postop nausea was lower for patients who had unrestricted fluid intake, 3.8% compared to 5.2% for patients who could take clear liquids up to two hours before. Postop vomiting was also lower, 2.2% to 2.8%.

The $64,000 questions is what concerns anesthesiologists the most. What are the aspiration risks with unlimited po fluid intake before anesthesia? Surprisingly, they were very good. Only two patients suffered aspiration of gastric contents. Both patients had risk factors including BMI>35 and history of gastric reflux. That compares to a normal aspiration risk of 1 in 8,000 anesthesia patients.

The researchers speculate that patients who were allowed unlimited drinking before surgery had less postop nausea and vomiting because hunger itself can cause nausea. Their conclusion is that the risks of gastric aspiration is low enough that it justifies patients being allowed to drink fluids to prevent the higher likelihood of PONV.

These numbers look very promising on paper. However, in the much more litigious U.S. legal system, I think I will continue to follow the ASA's guidelines instead. People normally go hours during the day without eating or drinking anything. They can certainly do that the day of their operations.

Surgeon Attacks Nurse. Guess Who Is Fired?

A charge nurse in a Beverly Hills surgery center has sued her former employer for abuse suffered at the hands of a surgeon at the facility. Paula Rickey, a nurse at the 90210 Surgery Center in Beverly Hills, has sued Dr. Kerry Assil, an ophthalmologist at the ASC, and Cedars-Sinai Health Systems, the center's corporate affiliate, with battery, sexual harassment, and discrimination in LA County Superior Court.

The alleged incident took place July 17, 2017. On video surveillance, Dr. Assil can be seen walking behind Ms. Rickey and hitting her on the back of her head. He reported grabbed her arm and told her, "I know I can do this because I know you like the abuse."

When she complained to her supervisors, the incident was reviewed by the hospital's board of directors and she was moved to a different floor. Eventually she had her hours reduced and was soon let go. She claims that despite Dr. Assil's reputation for arrogance and philandering with female employees, he was the ASC's medical director and brought a lot of business to the office. Thus he barely received a wrist slap for his behavior. The fact that other people are seen in the video just walking by the two of them as if nothing has happened shows how chronic this behavior must have been in the operating rooms.

Dr. Assil is one of those celebrity physicians frequently found in Beverly Hills. They can be seen on daytime talk shows espousing their knowledge to a national audience while drumming up more business for themselves. They are unlikely to be sanctioned by a hospital board as long as they keep bringing in well paying patients. Sometimes even having cameras in the OR's are not enough to bring justice to those abused.

Shut Up And Go To Sleep

The New York Times has a great piece about the increasing popularity of awake surgery. No, I'm not talking about the nightmarish scenario of being conscious while somebody cuts into your abdomen and you can't move or protest because you've been paralyzed. The article refers to using regional anesthesia to block pain sensations to the extremities while the surgeon operates. These are most likely to be used for hand or arthroscopic surgery.

Most patients who elect to be awake during their operations usually do it out of a sense of curiosity. Others are simply uncomfortable being rendered unconscious. A few prefer the quick recovery of not having had any sedation. They are able to drive home on their own right after their procedure.

However, there are downsides to having the patient alert in the operating room. They may not be able to handle the sight of blood and the sensation of cutting into tissue as well as they might have assumed in preop. But worse for the operating team, the patient may simply just want to talk too much due to their anxiety or curiosity. And guess who will be responsible for conversing with the patient? That's right, the anesthesiologist.

We are the ones at the head of the bed, behind the ether screen. We are the only person in the room that the patient can see continuously the whole time. Says Dr. David M. Dickerson, assistant professor of anesthesia at the University of Chicago, "You might have to make small talk throughout the entire case. They don't teach that in medical school."

That is exactly why patients should be sedated and preferably unconscious during an operation. The patient becomes a major distraction to every staff member working in the room. The surgeon has to watch what he says about the progress of the operation lest the awake patient thinks something is going wrong. He cannot confer with other surgeons or the anesthesiologist about the other patients on the operating schedule without violating HIPAA rules. The anesthesiologist is put in the position of making inane conversation to ease the patient's anxiety. Every alarm and beep on the monitor will trigger another question from the patient. Every instrument that gets dropped by the surgical tech will lead to the patient asking if everything is okay. This constant distraction from the work involved can lead to worse care. There just doesn't seem to be many advantages to keeping patients awake.

Lastly, the newspaper article has extensive quotes from surgeons and patients. Unfortunately there were comparatively few mentions of anesthesiologists. I would think the journalist would want more information from the professionals who make this miracle of awake surgery possible. Were the ASA or the ASRA contacted for their opinions of this hot new trend in medical care? If not, I think our professional societies need more work on their outreach to the media and public.

Drinking Before Surgery

It is one of the cardinal rules of surgical preparation; NOTHING by mouth after midnight, or NPO after MN. That is one of the easiest and most clear cut ways for an anesthesiologist to cancel a case. The surgeon will rarely argue with an anesthesiologist on this point. Some anesthesiologists adhere to this rule so strictly that they will cancel a procedure if the patient is even found chewing gum before surgery.

The reason we discourage patients from eating or drinking anything before receiving anesthesia is that we don't want any contents in the stomach during the procedure. If the stomach is full of food or liquids, there is a risk that the patient will vomit the half digested gastric bolus while under sedation and aspirate it into the lungs. This could lead to severe aspiration pneumonia and possibly death. The doctors and the hospital frown upon unexpected operating room deaths.

But now NPO after MN maybe getting a closer scrutiny. The American Society of Anesthesiologists has for years recommended that cases can proceed if the patient has only clear liquids up to two hours before surgery. Clears means anything that one can see through. Water is obviously considered clears. So is apple juice, grape juice, and, surprisingly, black coffee. Milk, orange juice, and coffee with cream are not clear liquids.

Now a study has been released that may actually encourage doctors to recommend patients have a drink before an operation. As Anesthesiology News reported, researchers at Texas Tech University Health Sciences Center had one group of patients drink a carbohydrate rich clear drink two hours before surgery and another group remain fasting after midnight. Not surprisingly, the group who got to drink before surgery felt less thirsty before their operation. But they also felt significantly less anxiety and greater comfort overall. The researchers concluded that perhaps patients should be allowed to drink clear liquids before they have their surgeries.

First of all I think that is a fine idea that should be further explored. While I would hesitate to let a patient drink as much as these study patients did, 360 mL of fluid which is a little more than one can of soda, I think a couple of gulps wouldn't hurt. We frequently ask our patients to take their medications with small sips of water before coming to the hospital and I don't know of anybody who has aspirated because of that.

Instead of using some specialized "carbohydrate rich beverage" that the researchers used (Clearfast and BevMD) which sounds very expensive, how about just letting patients get a small bottle of Gatorade or other sports drink? It is cheap and readily available. They also contain the electrolytes that are missing from plain drinking water.

Let's face it, NPO after MN is rather barbaric. No elective surgery starts at 2:00 AM. It is especially cruel if the patient's operation isn't scheduled until the early afternoon like 1:00 PM. Is the patient supposed to go without food or water for that long? They can do it but it is not comfortable. Plus by the time the patients comes to preop, they are so dehydrated that it makes starting an IV more difficult. The only reason we tell patients not to eat or drink anything after midnight, even for late starting procedures, is that just in case an early procedure gets cancelled, we can move another patient up without worrying about whether he had just drank something. The last thing the hospital wants is for an expensive operating room to sit empty while we wait for the two hour window to pass.

So let's do patients a favor and consider letting them drink a refreshment up to two hours before surgery. They will feel better when they come to preop. If they are happy, they will make your life better too.

Driving After Anesthesia

In the "Why didn't I think of that?" department, a new study appears to debunk the concept of having a driver available to take a patient home after outpatient surgery. In a study led by Asokumar Buvanendran, MD, he uses an computerized driving simulator to replicate the driving experience of patients before and after surgery. (Anesthesiology News, October 2009. Free registration required)

Current guidelines for outpatients are based on older, longer lasting anesthetics like diazepam and halothane. Consequently patients have always been advised to have somebody drive them home. If they did not have a driver, the case most likely would be cancelled. But what is the cognitive ability of patients now that mainly short acting anesthetics like propofol and midazolam are used?

In Dr. Buvanendran's study, a patient was tested in preop for fifteen minutes on the simulator. The patient then went to surgery. Afterwards, when the patient was cleared to go home from PACU, he was tested for another fifteen minutes. As it turns out, patients in postop actually had fewer accidents than they did preop.

Will this study change ambulatory surgery guidelines? Unlikely. In Canada, there are at least two malpractices claims that were brought by patients who were seriously injured in auto accidents after driving themselves home from outpatient surgery. Maybe as another condition for discharge from the PACU, all patients should play a course of Gran Turismo to see if they are mentally competent to go home.