How long are burn patients really NPO in the perioperative period and can we effectively correct the caloric deficit using an enteral feeding "Catch-up" protocol?

Abstract

"NPO at midnight" is a standard preoperative practice intended to reduce aspiration risk but can result in prolonged feeding interruptions in critically ill burn patients. Postoperative hyperalimentation in the form of a "catch-up" tube feeding protocol is routine. A retrospective review of our perioperative fasting practices and "catch-up" enteral feeding protocols was performed. Patients admitted to the Burn ICU from July 1st, 2015 to August 31st, 2016 were reviewed. Patients who had a protected airway in place, prescribed enteral nutrition, and underwent surgery were included. The time from NPO to surgical start (NPO-SS), NPO to feeding restart (NPO-FR), and calories received/prescribed were quantified. The efficacy of a postoperative catch-up feeding protocol was analyzed. There were 41 patients that fit inclusion criteria with some undergoing multiple surgeries, yielding 109 surgeries/discrete perioperative events. The average total body surface area burn (38.1±23.6%), age (38.8±20.1years), ICU days (45.0±37.3 days), and ventilator days (35.1±33.8 days) were calculated. Average fasting durations of NPO-SS and NPO-FR were 9.3±3.1 and 14.2±4.1h, respectively. The average caloric deficit to prescribed calories ratio during the NPO-SS and NPO-FR periods were 1154±629/3534±851kcal and 1765±928/3534±851kcal, respectively. A post-operative catch-up protocol completely compensated for perioperative caloric deficits 68.8% (22/32) of the time. In critically ill burn patients, a preoperative fast resulted in an average loss of greater than 50% of prescribed calories on the day of surgery. Clinicians should re-evaluate the standard practice of making preoperative patients "NPO at midnight". An effective catch-up protocol can adequately reduce caloric deficits.