Thursday, October 26, 2006

NPO after midnight

NPO = nothing by mouth. No food. No beverages - not even water. Standard instructions for adults and older children having surgery. As it turns out, that may be rather more strict than is absolutely necessary.

I already knew that pediatric anesthesiologists don't recommend long fasts for NICU babies prior to elective surgeries. I started researching the actual recommendations for adults last summer when my 20-something son was scheduled for elective surgery. 8 days prior to his surgery, almost a full page in the Baltimore Sun was devoted to the subject. The clinical director of anesthesia at University of Maryland Medical Center and several other anesthesiologists were quoted extensively in the article stating that clear liquids can usually be safely consumed up to 2 hours prior to surgery. If a patient asks, these physicians will even say so to the patient.

Not trusting the newspaper to get it right, I went on a hunt for more information and found that the reporter had been accurate. See the links at the bottom for more.

I presented all this to my son and asked what he'd been told, since all his printed information said quite clearly "NPO after midnight" for his 11:30 am surgery. It seems his surgeon was up to speed on the research and had OK'd water or other clear liquids 4-6 hours prior to surgery. My son opted not to take advantage of that information, but he was aware of it.

There is another reason surgeons prefer that their patients fast for longer than the mandatory minmum times. It makes rescheduling that much easier if it becomes necessary. Sometimes it does. While we were in the holding area about half an hour prior to my son's scheduled OR time, we heard another patient very profanely complaining that his procedure had been cancelled because certain necessary records were not available. He wasn't a bit happy. My son's OR time wasn't impacted, but someone else's probably was. I'm sure things like that happen all the time. Maybe not missing records, but changes in the OR schedule for a multitude of reasons.

I would never recommend that anyone disregard his or her physician's advice regarding preoperative fasting. There are too many variables and each case is different. It is worth asking, though, if your procedure is scheduled later in the day, whether it is safe for you to drink water and perhaps other clear liquids. You may be pleasantly surprised by the answer.

Food? Don't even go there! Depending on the reason for surgery and the nature of the food consumed, your stomach may not be empty many hours later. I was kept in the ER for nearly 12 hours prior to my appendectomy many years ago. I still threw up in the recovery room and woke up looking at an X-ray machine. Fortunately I didn't aspirate any of my stomach contents and end up in intensive care. It happens.

If your doctor wants you to eat, he or she will tell you to do that. Don't count on that happening and if you slip up and nibble on something in the morning, for goodness sake, ADMIT IT. Your life might depend on it.

Studies about fluid intake preoperatively:

Evidence Based Nursing 2004: Literature review "evidence is lacking that adults given liquids 1.5-3 hours preoperatively have a greater risk of aspiration or regurgitation than those given a standard fast"

Abstract from British Journal of Surgery on Ingenta Preoperative Fasting Findings recommend 2 hour fast from clear liquids for elective surgery for most healthy adults undergoing elective procedures.

Cochrane Collaboration -- another abstract which clarifies that pregnant, obese, elderly, and those with stomach disorders are more likely to regurgitate, but that healthy adults with none of the above may be able to drink water or other clear liquids up to 2 hours prior to surgery.

I think it's important to note the recommendations from the American Society of Anesthesiologists web site: (emphasis mine)

Why are patients not allowed to eat or drink anything before surgery?
For most procedures it is necessary for you to have an empty stomach so that the chances of regurgitating any undigested food or liquids is greatly reduced. Some anesthetics suspend your normal reflexes so that your body's automatic defenses may not be working. For example, your lungs normally are protected from objects, such as undigested food, from entering them. However, this natural protection does not occur while you are anesthetized. So for your safety you may be told to fast (no food or liquids) before surgery. Your doctor will tell you specifically whether you can or cannot eat and drink and for how long. In addition, the anesthesiologist may instruct you to take certain medications with a little water during your fasting time. For your own safety, it is very important that you follow these instructions carefully about fasting and medications; if not it may be necessary to postpone surgery.

Some degree of fast is clearly necessary. Fasting from food will almost certainly be recommended from midnight the night before. Ask your doctor his or her recommendations about liquid intake -- and then follow them.

Monday, October 16, 2006

Collaborative efforts

One baby in Nursery A and one in Nursery B. I get to guess whose parents will show first and which will need more of my attention, since my bilocation skills are a little rusty. 8 pm and every nurse in the unit had at least 2 babies due.

I was nearly finished with baby B (I'd elected to start with her, so I could spend more timewith family A) when the nurse practitioner appeared to inform me that the parents of baby A had arrived "with attitude" not improved by some bad news she'd had to share with them. Not terrible news, just one more thing they didn't want to hear.

Me: "Thanks, I'll be with them in just a minute. I just need to ....."

NP: "I can do that. What else do you need me to do so you can go take care of that mom in Nursery A?"

No, not wishful thinking. The nurse practitioner did everything I asked AND gave the medication I'd forgotten to mention, giving me the time I needed to soothe the mom who was about to have to go home weeks before her baby would be ready to join her. She could have stayed and talked to the mom until I got there, but she knew that what the mother needed was to hold her baby -- and that I needed to assess him before he came out of the isolette.

One of the things I like best about the nurse practitioners who work with us is that they have all walked in my shoes and they understand what they can do to make life easier for the nurses and for the families. That and they're willing to actually put out the effort when they have the time.

Wednesday, October 11, 2006

Homeschooling - Current Events

A friend who is the single mom of 4 boys decided to teach them an unforgettable lesson. She had heard that Fred Phelps -- yes, THAT Fred Phelps would be protesting the funeral of Marine Captain Justin Peterson. She took her sons to the funeral. Here's her story.

Today was the funeral for Marine Captain Justin Peterson. I didn’t know Captain Peterson, but I decided to take the boys to his funeral after we learned that Fred Phelps and his band of misfits intended to picket the Peterson funeral. Captain Peterson was killed in Iraq last week, and I thought it would be as good a time as any for the boys to learn that there are people like Captain Peterson in the world and that they owe him an enormous debt of gratitude for fighting to keep our country safe for them. It was also a good time to point out that although I loathe Phelps more than anyone I can think of at the moment, Captain Peterson died to protect the basic freedoms we all take for granted, most of all the right to free speech, even for people like Phelps. However, we were going to show support for the Peterson family . I don’t agree that Phelps should be using the funerals of servicemen and women as a public forum, so at 6 a.m. we were up and having breakfast so that we could be on the road by 8. More

Thursday, October 05, 2006

"I want you to do everything....."

"I want you to do everything....."

It's something you hear quite often in the NICU in regard to babies who have little or no chance of long-term survival. In my nearly 30 years as a NICU nurse, I can remember many such babies - and the famlies who loved them. They must make decisions that none of us would want to make.

Baby Martin (not his real name) was a full term baby who, for reasons never known to us, had seizures beginning on day 1 of life. It's been a long time, but I don't recall any birth trauma in his history. His NICU stay was relatively unremarkable and he was eventually discharged on anticonvulsant medication only to return to the ER a few weeks later. He'd had a seizure -- one much more severe than any we'd seen in the NICU.

He was admitted to the Pediatric ICU and his seizures, became more and more difficult to control. One study after another left his doctors puzzled and his condition deteriorated. Periodically, he would have a seizure so severe that his heart would stop. Each resuscitation was successful, but eventually it became obvious that the seizures could not be controlled and that his brain had been irreparably damaged. The doctors approached his mother to ask about simply letting him go if it happened again.

"No," she said. "If it is time for him to go, God will take him regardless of your efforts."

Puzzled and frustrated, they continued their aggressive interventions - including periodically resuscitating him.

One night I was floated from the NICU to the PICU. He wasn't my patient, I knew the pediatric resident from his NICU rotations. He had developed a relationship with the mother and was the one who spent the most time speaking to her about the baby's condition and prognosis. He knew I had also gotten to know the mom when the baby was in the NICU and asked for my thoughts on the situation.

"Does she understand what you're doing when you resuscitate the baby?" I asked.

He assured me that he had explained it fully to the mom and believed that she understood. He must have thought more about it, though. He told me later that he had asked the mom to stay for what proved to be the baby's final resuscitation. He had thought she understood. So did she. When she witnessed the actual resuscitation, she decided that this was more than she should be asking of the baby - and the staff. She decided that she would rather simply hold him and let him go.

Parents make choices based on what they believe is best for their child and we try to respect those choices. They seldom truly understand what they are asking when they ask us to "do everything." They must make some of the most difficult choices of their lives based on advice from people they may not know well at all and with limited understanding of the information we try to give them.

Tuesday, October 03, 2006

"We've hardly done any schoolwork today at all!"

Words from my youngest after we'd spent 2+ hours researching Aristarchus, ancient Greek astronomer and mathematician who is the first known to have theorized a heliocentric universe. Then we followed "rabbit trails" that lead us through an investigation of why we haven't managed to send any space ships to other galaxies yet. Short answer to that last question: We did. They aren't there yet. We learned that the Voyager I and II missions just reached the limits of our heliosphere within the last year (Scroll down to see the Voyager links)

We changed curriculum providers this year. The current one is called TRISMS. Time Related Integrated Studies for Mastering Skills. We're using the middle school version titled History Makers It's a survey of world history following biographies and achievements of scientists and explorers. We'll be reading some historical fiction and many biographies. When available, we may even look at some primary sources and we'll be checking internet resources -- if only so my son can figure out why those aren't always reliable.

#1 skill on the agenda -- research. Finding answers to your questions and figuring out whether or not they're valid. We start with a list of explorers and scientists, but are encouraged to stray outside the written boundaries of the program. I understand that the high school levels of the program encourage students to find one focus -- music, art, food, medicine, etc. and follow it through the ages as they make their way through the program.

The program incorporates vocabulary, grammar, history, science, geography and art -- most of the middle school agenda. We can incorporate the music of the cultures as well if we do a little additional research. We won't do much of that this year as keeping up with his piano lessons keeps us pretty busy musically.

In addition, we're learning Latin using the Prima Latina program from Memoria Press. It's designed to be used with kids as young as Kindergarten, but works well as an intro for a 6th grader too since it incorporates the Latin Prayers he wanted to learn. His goal is to eventually be able to converse in Latin with the Legionary priests and brothers who assist with the Conquest Club he sometimes participates in.