University of Illinois Hospital tells patients to drink something up to 2 hours before surgery

Anyone who has had surgery is familiar with this phrase: “Don’t have anything to eat or drink after midnight the night before your surgery.”

The request, known as an NPO order — for nil per os, Latin for “nothing by mouth” — ensures that most patients arrive for their next-day surgery thirsty, hungry, and if they are heavy coffee drinkers, in the throes of a caffeine withdrawal headache. Hardly the condition you want to be in before going into surgery, notes Dr. Randal Dull, professor of anesthesiology at the University of Illinois Hospital.

That is just one of the reasons why the hospital is now one of just a small percentage in the United States to have dropped the NPO order for surgical patients. In 1999, the American Society of Anesthesiology revised its practice guidelines to allow patients clear liquids much closer to the time of surgery than midnight the night before surgery, but very few hospitals changed their own pre-surgical planning routines based on the new guidelines.

The NPO order is actually a holdover from a time when patients were anesthetized using ether and chloroform, and vomiting was common, Dull explained. “The thinking in the modern age is still based on the idea that if a patient has something in his or her stomach, the patient could vomit under anesthesia and potentially aspirate, or inhale his or her vomit during surgery,” said Dull.

“The aspiration fear is just not based on any scientific evidence,” said Dr. Ari Rubenfeld, assistant professor of otolaryngology in the University of Illinois at Chicago College of Medicine. “We were taught that all surgical patients were to be NPO after midnight while we were in medical school, but it’s no longer an example of best practices. More interesting is that the practice hasn’t effectively changed, even when the major professional anesthesiology society in the U.S. issues a new guideline effectively killing the NPO order as it stood.”

In 2016, Dull, Rubenfeld and Julie Moore, a clinical nursing consultant at the University of Illinois Hospital, led a multidisciplinary task force to improve surgical patient outcomes and experience. They quickly zeroed in on the NPO order as the first thing that needed to change.

In May 2016, the hospital revised pre-op instructions to encourage patients to drink clear liquids up to two hours before their surgeries. In their pre-surgery instruction packet, patients are given a packet of sports drink powder, and are instructed to mix it into three cups of water and drink half before going to sleep the night before surgery, and to drink the remaining half when they wake up the day of surgery. Once patients arrive at the hospital, if their procedure is expected to start in more than two hours, they are encouraged to have additional clear liquids — water, apple juice, more sports drink, or even coffee without milk, which is considered a clear liquid.

“Having clear liquids, especially liquids that contain some carbohydrate, like sports drinks or juice, not only helps improve patient outcomes, but our patients also feel better before and even after their surgery,” said Rubenfeld.

Some studies also suggest that surgical stress can result in insulin resistance and hyperglycemia and that consumption of carbohydrate beverages can reduce insulin resistance during and after surgery. Having liquids closer to surgery can also help with starting intravenous lines. “For some dehydrated patients, it means its harder for us to find a vein to start IVs, and patients get poked multiple times. By allowing liquids up to two hours before surgery, these complications are reduced,” said Dull.

Today, about 98 percent of UI Hospital patients follow the new guideline and have something to drink up to two hours before their surgery. The success of the new program is due largely to staff education. “The NPO order dogma is so ingrained, that we knew we would have to launch a coordinated, intensive educational campaign to get everyone on board,” said Moore. “We needed to effect a core cultural change in what we tell our pre-operative patients.”

“The acceptance of this initiative has been very impressive. We’re proud to say we have almost total compliance from the staff in how they are instructing patients to prepare for surgery regarding the new guideline around having something to drink,” said Dull.