Point - Counterpoint
Commentary
The writers for this point/counterpoint have certainly chosen a relevant topic to review. NPO guidelines come up nearly every day and often several times in a day at my hospital.
Cases are delayed and the infant is fussy, should we allow the child some PO intake? If we do allow it, may the child have formula or only pedialyte? How about apple juice? orange juice? Another child was inadvertently given PO intake within the past hour but he has been here twice previously and was cancelled for URI and /or fever. The surgeon is leaving town this afternoon and only has time for the case now. The family is not well off. Both parents have taken off from their tenuous employment to be with the child for, what for them, is a frightening experience. Must we really cancel the case again? I asked Solomon to comment on the resolution of dilemmas such as these but did not get an answer
Clinical decisions are made about the wisdom of proceeding with a particular case either on very subjective grounds or, at the other extreme, based on very strict adherence to the published guidelines. There is nothing I can add of a factual basis to the comments of the two writers. Drs Lauro and Greco have beautifully summarized the current published information on the topic and also characterized the quality of that information. The take-home message for me is the one should remain flexible when faced with a clinical decision about whether to delay, reschedule or proceed immediately with an elective procedure when the NPO guidelines may not have been followed to the letter. While an elective case should certainly be rescheduled if, during the preanesthetic interview the child finishes his breakfast, I think it very important that the NPO times a particular institution chooses should always be named guidelines to allow clinicians latitude in the care of a particular child. The variability of the results regarding gastric residual, pH following a variety of NPO times and types of oral intake cited here supports this approach.
Thomas J. Mancuso, MD, FAAP
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