NPO Guidelines for ERCP Procedures
Patients undergoing ERCP should be kept strictly NPO (nothing per oral) for at least 6 hours before the procedure to minimize the risk of aspiration and procedure-related complications. 1
Standard NPO Guidelines for ERCP
- Patients should discontinue solid food intake at least 6 hours before the procedure 1
- Clear liquids may be permitted up to 2-4 hours before the procedure, but should be discontinued thereafter 1
- Medications that affect coagulation or platelet function should be managed according to specific guidelines, as ERCP is classified as a high bleeding risk procedure 1
Rationale for NPO Status
- ERCP is classified as a high-risk endoscopic procedure with potential for significant complications including post-ERCP pancreatitis, bleeding, and perforation 2, 3
- Strict NPO status reduces the risk of aspiration during sedation or general anesthesia, which is particularly important as patients are often positioned prone or semi-prone during the procedure 4
- The procedure often requires deep sedation or general anesthesia, making airway protection critical 1
Special Considerations
Anticoagulation Management
- For high-risk endoscopic procedures like ERCP, specific anticoagulation management is required:
- Warfarin should be discontinued 5 days before the procedure with INR checked to ensure it's <1.5 1
- Direct oral anticoagulants (DOACs) should be discontinued at least 48 hours before the procedure (72 hours for dabigatran in patients with CrCl 30-50 ml/min) 1
- For high thrombotic risk patients, bridging with low molecular weight heparin may be necessary 1
Positioning Considerations
- While ERCP is traditionally performed with the patient in prone position, the procedure can be performed in either prone or supine position without significant difference in technical success 4
- The prone position is generally preferred as it provides better anatomical alignment of the bile and pancreatic ducts and may reduce the risk of aspiration 4
Post-ERCP Feeding Guidelines
- Early oral feeding (within 24 hours) is recommended after ERCP rather than keeping patients NPO for prolonged periods 5
- Maintaining enteral nutrition helps protect the gut mucosal barrier and reduces bacterial translocation, thereby reducing complications 5
- Routine or empiric orders for extended NPO status after ERCP should generally be avoided 5
Common Pitfalls to Avoid
- Failure to properly assess and manage anticoagulation status before ERCP can lead to increased bleeding complications 1
- Inadequate NPO time increases aspiration risk, particularly important as ERCP is often performed in prone position 4
- Unnecessarily prolonged NPO status after the procedure can lead to nutritional deficits and delayed recovery 5
Special Patient Populations
- For pregnant patients undergoing ERCP, the same NPO guidelines apply, but these patients should be positioned in left lateral or left pelvic tilt position in the second and third trimesters to avoid compression of the aorta or inferior vena cava 1
- In patients with acute cholangitis requiring urgent ERCP, NPO guidelines should still be followed when possible, but the procedure should not be delayed if clinically urgent 1