Does a patient need to be NPO (nothing by mouth) for an Interventional Radiology (IR) chest tube insertion?

NPO Status for IR Chest Tube Insertion

Patients do not need to be kept NPO (nothing by mouth) for an interventional radiology chest tube insertion, as this is a procedure typically performed under local anesthesia with minimal sedation.

Evidence-Based Rationale

The available guidelines do not specifically mandate NPO status for chest tube insertion procedures. While some procedures requiring deep sedation or general anesthesia have clear NPO requirements, chest tube insertion typically falls into a different category:

Procedural Considerations

• Chest tube insertion is commonly performed under local anesthesia with or without minimal sedation 1
• The procedure does not typically involve manipulation of the airway that would increase aspiration risk
• The 2022 ERAS Society guidelines note that traditional NPO after midnight practices are associated with patient discomfort, dehydration, electrolyte abnormalities, and increased anxiety without clear benefits 1

Risk Assessment

When considering the need for NPO status, the following factors should be evaluated:

1. Level of sedation required:

   • Most chest tube insertions require only local anesthesia
   • If minimal/conscious sedation is used, the risk of aspiration is very low

2. Patient-specific factors:

   • Underlying conditions that might increase aspiration risk
   • History of gastroesophageal reflux disease
   • Level of consciousness/mental status

3. Urgency of procedure:

   • For emergent chest tube placement (tension pneumothorax, large symptomatic pneumothorax), the procedure should not be delayed for NPO status 1

Special Considerations

The 2019 JACC Council Perspectives on sedation for cardiologists provides relevant guidance that can be applied to IR procedures:

• For scheduled procedures with minimal sedation, traditional NPO restrictions may be unnecessary 1
• For unscheduled/urgent procedures (such as emergent chest tube placement), the procedure should not be delayed for NPO status 1

A 2023 review specifically examining NPO orders for elective cardiac procedures found that "strict fasting requirements should be reduced, and a more nuanced fasting protocol based on individual patient characteristics and risk factors should be utilized given the overall low risk of aspiration with elective procedures utilizing procedural sedation" 2.

Practical Approach

For IR chest tube insertion:

1. For emergent chest tube placement:

   • Proceed without delay regardless of NPO status
   • Use local anesthesia with minimal or no sedation if possible

2. For elective chest tube placement:

   • If using only local anesthesia: NPO status is not required
   • If using minimal/moderate sedation: Clear liquids may be permitted up to 2 hours before the procedure 1
   • If using deep sedation (rare for chest tube insertion): Follow standard NPO guidelines (clear liquids up to 2 hours, light meal up to 6 hours before)

Conclusion

Based on the current evidence, routine NPO orders for chest tube insertion procedures are unnecessary when performed under local anesthesia with minimal sedation. This approach aligns with modern procedural sedation practices that recognize the low risk of aspiration with minimal sedation and the potential harms of prolonged fasting.