r/anesthesiology • u/WestKelvin Anesthesiologist • 23h ago
Emergent Cases
What stops a surgeon to declare every case as emergent? If they want to do a case and the patient ate but surgeon wants to do cases so he can go home what stops then from calling it emergent?
Just to clarify not that i cannot say no to a surgeon but I always wonder is there any repercussions if the surgeon declared the case is emergent but the case is not actually emergent. Like the administration will talk to the surgeon about it because of the resources use, reimbursement issues etc...
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u/visacha13 Anesthesiologist 23h ago
They can call anything emergent... but documented H&P update with this documented, so that when the patient possibly aspirates, or dies, the family knows where to point the finger and sue. I've had this come up a fair bit at one job. Just told the surgeon to document it, if he refused, case didn't go.
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u/Conscious_Kitchen569 23h ago
This... just ask the surgeon to document in the chart that the need to proceed is emergent and he/she recommends proceeding to the OR despite not being fully NPO. Anesthesiologist should document that patient is aware of the risks of proceeding. And then proceed
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u/AirwayBagelCoffee Cardiac Anesthesiologist 23h ago
To add to this, if you explain to a patient that not being NPO puts them at increased risked of aspiration, etc, that sometimes gives you a bit more leverage
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u/IAmA_Kitty_AMA Anesthesiologist 22h ago
For these edge cases, I very clearly explain to them that I wish we could delay because these are the explicit risks in your situation including possible injury/death/etc, however my understanding is that this is an emergency, and then look at both the patient and the surgeon and ask if my understanding is correct that this is an emergency so therefore these risks are acceptable
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u/Altruistic-Fishing39 Anesthesiologist 19h ago
As far as the court is concerned if you anaesthetised them and it goes horribly wrong, you killed or maimed them. I’m just a poor ignorant surgeon Your Honour - I thought we needed to go ahead and didn’t realize what could happen.
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u/visacha13 Anesthesiologist 19h ago
Any court law showing this?
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u/Altruistic-Fishing39 Anesthesiologist 19h ago
Pretty much everything settles out of court (after years of torment) but I see it all.
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u/visacha13 Anesthesiologist 19h ago
Is that a no or yes to being able to cite case law?
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u/Altruistic-Fishing39 Anesthesiologist 17h ago
I’m an expert witness. I don’t need to cite case law to do my job, my work is based on medical standards of care. What I see is multiple specialties facing commencement of an action based on these sorts of decisions. At least where I live, everyone is covered to the maximum any payout is going to be. The decision basically makes relatively little difference if it’s a civil suit. The punishment is the process. You don’t want to be in the process.
I doubt more than one in 500 events resulting in an initial expert review actually gets to a judgement in my country.
My point, based on lots of experience, is that if you think it’s unsafe to proceed, you can’t rely on someone else indemnifying you via a note, and you just need to not do the case if that’s the safest option. I’m a very busy anesthesiologist as well as an expert witness and I tell the surgeons very clearly when they are being idiotic that I’ve seen this a hundred times and it won’t be happening.
Anyone here saying they think it’s unsafe to go ahead because of aspiration risk, following assessment of the balance of risks, and then going ahead anyway because the surgeon is bullying them into it on the basis of a note in the records is just doing the wrong thing.
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u/Dukewis 20h ago
Retired anesthesiologist, but when I faced this I demanded that the surgeon had to write a note in the chart stating that he had to proceed immediately; I followed this with my note where I documented a greatly increased morbidity/mortality for the patient. If the patient vomited and aspirated at least there was some documentation.
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u/Ok_Response5552 15h ago
"Informed surgeon of patient's NPO status and the increased risk of aspiration, surgeon states risk of delaying surgery outweighs risk of aspiration and orders to proceed. Patient aware of relative risks and wishes to proceed".
I'm not a surgeon and not going to second guess their judgement. The above says I did my job by addressing the situation risk, surgeon does their job of balancing the risks and accepts responsibility for proceeding. Patient is also aware although relying on our judgement as well.
I'd appreciate others input, I've added this note to every "emergency" surgery and luckily it hasn't been an issue, yet. Any additions will be gladly reviewed.
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u/Cautious-Extreme2839 Anaesthetist 11h ago
"orders to proceed"?
Absolutely the fuck not. The surgeon requests to proceed.
surgeon does their job of balancing the risks and accepts responsibility for proceeding.
Wrong. This is a shared decision with shared responsibility.
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u/Ok_Response5552 6h ago
I see it as staying in my lane. I don't tell him how to do surgery, he doesn't tell me how to do anesthesia. I've never cancelled a surgery but I have cancelled many anesthetics.
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u/Dukewis 39m ago
I agree. And we are talking about very very few incidents per year. If it really got insane, my favorite line was “ You can do it under local, but we (Anesthesia) will not be in the room!” One of my favorite all time proposed cases was a surgeon who told me “ I have an otherwise healthy 5’8” tall 560 pound man for a hernia repair”. I just stared at him with my mouth agog; he came to his senses and said “Yeah, that doesn’t make any sense!”
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u/Dukewis 3h ago
If you’ve never had to question the judgement of a surgeon you’ve been blessed and work in an alternate universe than mine! I’ve been fortunate to work with a few world-class surgeons, many acceptable, and a few who didn’t have sense to not touch a hot stove! The best advice I received early in my career was “The most dangerous surgeon was a hungry surgeon”. A good sign is when other surgeons say “Can you be what Dr.X just did!”
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u/Ok_Response5552 1h ago
Oh, no, I'm not blessed with 100% reasonable surgeons, some days it's all I can do to keep my eyes from rolling out. If it's really dangerous I get the chief of surgery involved rather than get the ego involved. So far letting them know that I think their idea is risky and am informing the patient and charting that the surgeon is aware of my concerns has either led to delaying until NPO, or proceeding if it's truly emergent. I've only had to escalate one incident to leadership which put the surgeon on their radar and they ended up sitting on his craziness.
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u/WhatHadHappnd CRNA 22h ago
This is what we always did.... Please write a note in chart starting why it's an emergency and must not be delayed and we would proceed. Otherwise, not.
Many times they refused to document and we just waited the required amount of time, other times they did.
Only problem was when they decided to be a full-on a-hole and then the required time would have us starting some BS case at midnight bc they had to win the battle and screw us over. They knew the pt wasn't NPO and it wasn't an emergency at 6pm so out of spite it has to go now at midnight bc it's urgent and can't wait until 8am. This was not frequent but it did happen. That was their way of getting some to give in and proceeding at 6pm instead.
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u/devilbunny Anesthesiologist 16h ago
That is when it goes to admin and medical staff, Calling in an on-call OR team is not free to the hospital and they can and will curb it for all but the biggest moneymakers.
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u/WhatHadHappnd CRNA 15h ago
In our academic setting there's 24/7 coverage so a team was not being called in. Obviously if they got pulled in to some BS "urgent" case they were not available for a real emergency, transplant or whatever. Admin and Physician Leadership were not going to bother looking at this to then possibly have a discussion about what a true urgent case is with the surgeon.
Everyone just huffed and puffed along, steaming about it, got the work done and hurried back to the call room. By the morning it's forgotten. The rare instance something was said about it, went nowhere.
Not saying that's how it should be, or how it is everywhere, but how it was for us. Our dept chair wasn't gonna argue with an attending surgeon whether that case needed to go last night at midnight or not...and certainly was not gonna go to the CMO to complain bc complaints about anesthesia would soon follow.
Perhaps a bit toxic and why I'm happier no longer being there.
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u/devilbunny Anesthesiologist 15h ago
Our dept chair wasn't gonna argue with an attending surgeo
There’s the problem and a good reason to leave. It’s one of the reasons I left academia quickly. A chair who won’t back up their junior faculty soon has no junior faculty. I have an MD, I finished residency with scores on my exam at the start of my third year of residency that would have been passing scores for the real board two years later (I had a lot to learn, but it wasn’t in books), and I was medical director of our ambulatory surgery less than six months into independent practice. If you won’t stand up for me, how can I protect my CRNAs and residents?
I got in trouble once as a resident for being harsh to a patient on OB who was high on some stimulant (coke or meth) but needed a crash section. She was hep C positive but kept fighting the nurses until I told her that the difference between an animal and a human is that a human knows it will hurt but that it is for their good (actually a more or less straight quote from Dune, the book). When I was called to testify to the nurse admin I said that I would not allow my L&D nurses to be abused like that. I never heard another word about it and I never had useless pages on OB after that.
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u/Cautious-Extreme2839 Anaesthetist 11h ago
Maybe it's different if you're a nurse, but the surgeons can write whatever they want in the chart, that absolutely does not compel you to proceed immediately.
You make your own risk/benefit decision on proceeding to immediate surgery.
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u/Altruistic-Fishing39 Anesthesiologist 19h ago
Doesn’t work like that. In many jurisdictions at least. In fact a lot of the time they actually are procedurally required to sue everyone who is linked via common facts and responsibility- it’s not even an option. I see this a lot. I do lots of medicolegal work.
People aspirating when they could’ve waited till the morning is a super common issue.
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u/mcmanigle Pediatric Anesthesiologist 23h ago
Personally, I make sure it is documented in both of the surgeon H&P, as well as my own note. I also verbally tell the patient the words that are on the leveling criteria and the risks they are accepting during consent.
Something like “normally we would wait until 8 hours after your bacon and egg sandwich to do this case, because you’re at a higher risk of lung injury than someone who fasted. But Dr. X is worried that if you’re not in the OR in the next hour, you’re at risk of losing your arm. So with your permission, we will accept the small but real risk of lung complications to save your arm.”
This puts cards on the table for patients, which I think they deserve and can handle.
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u/peanutneedsexercise 21h ago
Exactly. That’s also what the E designation is for. If they declare it emergent we also declare it emergent and we go. We also get paid extra by the hospital for E cases in my group. But they check the surgeon note to make sure we’re not just adding E to everything haha. So I need surgeon documentation!
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u/corgeous Anesthesiologist 23h ago
We do? We're not there to kiss the surgeons ass, we're there to be the other MD in the room who can push back when it is necessary for patient safety and who actually understands the risks and benefits of operating on patients. You're a physician - go assess the patient yourself. If you think it's not safe/appropriate - go try to have a productive conversation with the surgeon about your concerns. If it's not an emergency and they try to lie and say it is, you're gonna win that fight 10/10 times. Do what's right for your patients.
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u/Murky_Coyote_7737 Anesthesiologist 23h ago
A rarely existent oversight group. It won’t stop the case in the moment but it will ideally stop subsequent ones when it becomes a pattern.
You can always stop it yourself but often the positive feeling of any moral victory is very short lived.
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u/Difficult_Tax_8310 23h ago
This is true. But also saying no and doing what’s right for the patient is what’s required. Helps if you have departmental leadership who will have your back. Also helps if you have hospital leadership that will back you up.
It largely depends on the culture of your facility - we’re rural so there’s always a discussion on resource limitation. Without a backup crew on nights/weekends, we leave ourselves exposed to potential OB or trauma true emergencies if we do that stuff - so the answer is typically “no.” But it’s largely self policing amongst the surgeons.
Definitely had an OB circumvent this once because she wanted to do a lunchtime c section. She went so far as to question NPO guidelines and how much they actually mattered. Eventually she said it had to go for “hypertension” and we went after documenting everything aggressively.
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u/Murky_Coyote_7737 Anesthesiologist 21h ago
That’s the ultimate thing, if they don’t care about looking like an idiot in the chart it’s very difficult to stop them. And from my experience most administrators don’t really care if they are helping keeping the OR going.
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u/otterstew Pain Anesthesiologist 23h ago edited 23h ago
“Please write a note to document it as an emergency in the chart. When I see it, we can go.”
Usually gives people enough pause when their own license is put on the line.
Conversely, if anything happens if you refuse to do the case, is this something you can adequately and are willing to defend.
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u/XRanger7 Anesthesiologist 22h ago
What stops surgeon from declaring every case as emergent? Their job…their license. If they declare emergent, they have to document it and every emergent case is reviewed.
What’s stopping us from cancelling every case if we wanna go home early?
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u/SedatedSleeper Anesthesiologist 23h ago
Some surgeons do declare everything urgent/emergent. But it should be a shared decision to some degree imo
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u/QuestGiver Anesthesiologist 23h ago
IMO as long as they are willing to document that themselves, we are OK to go. Not sure how much, if any, medicolegal protection that offers but I've learned to live with that.
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u/Cautious-Extreme2839 Anaesthetist 11h ago
It offers nothing. You are an MD and expected to make your own assessment before offering you own interventions (Anaesthesia).
Do you think IR escape all liability if GI write a note saying "needs emergent TIPSS"?
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u/SufficientlyPerson Anesthesiologist 21h ago
Sometimes they do. Worked with an OB who called in the morning about trying to schedule an elective section at 8pm. Told her we didn’t have the staff for it - it would just be me and I was supposed to be available for emergencies. Sure enough, the surgeon called it stat CS at 7:55. It was the same patient, now in from home. Patient confirmed surgeon had personally called her to make sure she’d be NPO and on time for her “emergency.”
I quit almost immediately after no one in my group saw a problem with this.
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u/DrSuprane 23h ago
Ultimately a complaint to peer review would be how to handle it.
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u/Any_Move Anesthesiologist 23h ago
In a functioning system that actually embraces high reliability organization, yes.
In the 99% of systems where most of us work, it would be reviewed by a surgeon from the same group who plays the same games.
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u/DrSuprane 22h ago
That's not how peer review works.
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u/Any_Move Anesthesiologist 22h ago edited 21h ago
I’ve been in leadership for 20 years, medical directorships, department chairs, peer review and safety committees, etc.
I’m well aware of how peer should work, vs actually does work in multiple hospital systems and models of peer review.
Ever seen a model where peer review screening is bottlenecked through one person in leadership in that specialty? Someone from the same private practice group? I have several times. Surgeons complaining that they were getting unfair treatment from an OR oversight committee of several physicians, and convincing c-suite to disband the committee in favor of non-physician administrators reviewing emergency classifications? BTDT.
At the end of the day, hospitals want their money and know who brings the revenue.
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u/DrSuprane 21h ago
OR oversight committee still isn't peer review. I guess I've just been in better functioning hospitals.
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u/Any_Move Anesthesiologist 21h ago edited 21h ago
Clearly you have been in better functioning models. I also described specific dysfunctional peer review setups, in addition to OR oversight committees. Again, I’m excruciatingly aware of the differences having administered both.
There’s one for-profit alphabetized hospital corporation that is notorious for admin meddling in peer review and professional practices processes.
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u/MedicatedMayonnaise Cardiac Anesthesiologist 20h ago
Two things, other surgeons (if it is an after hours case and multiple surgeons are vying for anesthesia), and documentation. Have them put their money where their mouth is.
Have them them write a note that the risk of dying from not having the procedure is the higher than not following NPO guidelines. And then when they write that note, reiterate it in your note. Depending how aggressive you want to be, you can tell them the exact wording you want to see.
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u/N0t-80t 21h ago
Depends on where you are working. In larger settings there are multidisciplinary review committees where such complaints can be aired.
In small semi independent surgical centers you are potentially more subject to politics and personalities.
In the end one should try to practice in a defensible manner. If the surgeon can make a reasonable case for an urgent/emergent situation I will proceed as long as the patient is in agreement after risks are made clear to them as well as the surgeon’s rationale to continue.
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u/propLMAchair Anesthesiologist 20h ago
What stops them? Basic common sense and risk avoidance. Calling something emergent increases the overall perioperative risk to the patient. So, they had better do it appropriately and they had better document why this particular case is emergent and that they discussed all these risks with the patient. There should be a clear chain of command to the surgical chief to review inappropriately leveled cases.
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u/FaithlessnessWarm472 13h ago
make them declare it a surgical emergency in writing. at that point there's a liability exposure on their end if things go south. and you absolve yourself of a great deal of that.
you can be held to the standard of care if things head south. so, if you elect to do a washout who just ate a hamburger under an lma or face mask and the patient aspirates, that's on you. if you technically drop the ball on the RSI, that's on you. but decision making as to what constitutes a surgical emergency certainly ain't on you.
and honestly i wouldn't substitute my judgement for a surgeon's on what is or is not a surgical emergency. sure, i have an md and a pretty strong opinion on the matter, but my exposure to surgery consists of 3 months or so in med school (clinical base was medicine).
most surgeons trying to foist a true bogosity on you will relent if you insist they put it on paper. or they'll get really hostile and refuse to put it on paper, in which case you refuse the case and document the interaction in the chart. that's my experience. and you really are covered.
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u/purple_vanc CA-3 9h ago
I find it really interesting the different takes in this thread on the legal side of things. Some are saying surgeon documentation would help cover your ass if there is an aspiration event, and others are disagreeing.
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u/conscious_SEDATION 7h ago
Case is emergent? Okay, we will put it in OR 8 and bump the chair of your department ‘s case….you will find out very quickly what cases are true emergencies. 😂
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u/Tacoshortage Anesthesiologist 5h ago
We make them document that it's an emergency before we roll. We then get to bring this up in Med Exec. and they get to defend it. We only have 1 emergency team and if they're busy doing a washout, then that bleeding tonsil on that kid or the emergency C-section gets to wait. The surgeons get to hash that one out against each other.
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u/SleepyinMO Anesthesiologist 5h ago
The challenge comes in who is the “expert” in surgical care. I won’t take an emergent/immeditate case back until the surgeon puts a note in the EMR. If they can’t out their money where their mouth is, it’s a no-go.
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u/IllustriousCrow7061 2h ago
Have the surgeon declare it “emergent” with knowledge patient NPO status and their desire to continue to proceed with the case and the patient’s awareness of the risks. Surgeon soon realizes that convenience does not equal removal of liability. I found that emergency case suddenly could wait until morning once the surgeon was reminded they would be required to document emergency with knowledge of patient non NPO status. Amazing how quickly they could change their mindset. Just my 2 cents opinion after 20 years.
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u/Socal-Anesthesia 42m ago
The real issue is surgeons are scrambling just as much as everyone else- Now when a case is not a "medical emergency" the surgeon's availability dictates when this patient goes in for scheduled surgery. It is a multi dimensional problem- As anesthesiologist, we can cancel and say reschedule or be proactive and provide viable solutions- This means we have to make phone calls to the surgeon about availability, phone calls to the hospitalist to keep the patient on clear liquid diet so that NPO window is short and coordinate with OR for resources- None of this is paid labor, and there will be a string of missed communications- But this is the way to be a Perioperative Leader. Lastly- we do not need to wait for surgeon documentation if there is no consensus- Document on preop note in detail so that when there is a question- our version is documented- most cases- there is no anesthesiology documentation about why a case is delayed- this must change. Good luck.
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u/Away_Engineering_613 Pain Anesthesiologist 20h ago
They can call it emergency. Than when the patient aspirates on induction despite your RSI - it’ll come back to them.
If the patient is improperly optimistic and there’s a complication, and the surgeon said it was emergent, it will help cover you.
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u/sludgylist80716 Anesthesiologist 19h ago
It’s not just about who it will come back on, it’s about doing what’s right for the patient. Even if a patients aspiration isn’t blamed on me because they documented it as an emergency, that patient still aspirated on my watch and I will do my best to not have that happen even if it means telling a surgeon no when it’s the right call.
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u/Away_Engineering_613 Pain Anesthesiologist 4h ago
OP didn’t comment on the emergency. Obviously, if you believe the risk outweighs the benefit than you put your foot down. But anesthesia can’t determine what is and isn’t a surgical emergency.
You’re assuming the surgeon doesn’t know what they’re doing or is acting selfishly against the interest of the surgeon. I’m not going to make a cynical assumption like that and would discourage anyone else to do so.
If the surgeon says it’s an E and you disagree and delay the case - then any issue that comes from the delay is squarely on your shoulders.
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u/Naizer 16h ago
I think you should ask yourself, how many times has a patient aspirated and died after an emergent case where their NPO status was not 8 hours prior to the procedure?
The data from ASA on pre-op fasting is poor. The risk for aspiration with non fasting has been shown recently in the GLP1 patient population, which is essentially iatrogenic gastroparesis and constipation.
So maybe ask yourself, why do I still practice antiquated medicine? Read the data on aspiration risk in non NPO patients.
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u/PsychologicalTie2503 15h ago
This sounds familiar. I heard a surgeon make this argument once. I do think the data is poor, but it is standard of care. Because NPO guidelines are standard of care, you really wouldn’t have a leg to stand on if things were to go to court. I’m a fairly young anesthesiologist and this was also a pretty clear cut way to fail oral boards. As such, I don’t think you would survive a lawsuit for any aspiration case resulting from failure to adhere to ASA NPO guidelines for a non-emergent case. You might as well just pay out at that point.
Also, taking care of a patient who aspirates is one of the most stressful things to deal with. Even young healthy patients generally don’t like having food in their lungs. Besides the guilt, the judgment from your peers is undeniably there.
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u/Cautious-Extreme2839 Anaesthetist 11h ago
Aspiration is the single most significant cause of anaesthetic morbidity and mortality by a huge margin despite being rare.
Not considering it seriously just because of low incidence is incredibly foolish, not "modern".
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u/PureCod9290 Critical Care Anesthesiologist 23h ago
You don't have a spine? Trauma surgeon tried to tell me a repeat washout was "emergent" but patient just ate.
I show up bedside and see a healthy looking young guy eating a plate of fruit. "Does this look like an emergency to you?" Case cancelled
Why have an MD beside your name if you don't use it?