What is the proper protocol for placing a Nil Per Os (NPO) at midnight order?

How to Place an NPO at Midnight Order

The traditional "NPO after midnight" order should be abandoned in favor of evidence-based fasting guidelines that allow clear fluids until 2 hours before surgery and solid foods until 6 hours before surgery for most elective procedures. 1, 2

Modern Fasting Guidelines Replace NPO at Midnight

The outdated practice of ordering "NPO after midnight" has been superseded by current evidence-based recommendations:

For Elective Surgery Patients

Standard fasting requirements:

• Clear fluids permitted until 2 hours before anesthesia 1, 2
• Light meals/snacks allowed until 6 hours before surgery 1, 2
• Full meals require 8 or more hours of fasting 2

These guidelines apply to ASA Class I or II patients without specific contraindications such as morbid obesity, gastrointestinal disease, or gastroparesis 3.

Preoperative Carbohydrate Loading

Instead of traditional overnight fasting, consider ordering:

• Oral carbohydrate drinks the night before surgery 1
• Clear carbohydrate-containing fluids until 2 hours before anesthesia 1

This approach reduces perioperative discomfort, anxiety, and postoperative insulin resistance 1.

When NPO Orders Are Actually Needed

High-Risk Patients Requiring Traditional NPO

Maintain stricter NPO protocols for:

• Patients with suspected stroke (NPO until formal swallowing assessment completed) 2
• Patients with gastroparesis or severe gastroesophageal reflux 3
• Morbidly obese patients 3
• Patients with gastrointestinal obstruction or severe motility disorders 3

Emergency Surgery

For emergency procedures:

• Assume full stomach regardless of fasting duration 1
• Consider rapid sequence intubation techniques 1

Special Population Considerations

Hospitalized Patients with Cirrhosis

Minimize fasting periods aggressively:

• Maximum interval of 3-4 hours between nutritional intake while awake 1
• Implement strategies to minimize NPO duration (pre-bedtime snack, early-morning snack if procedure is late afternoon) 1
• Consider advancing diet rapidly when no indication for NPO status exists 1
• Identify and address barriers to oral intake promptly 2

Patients with Inflammatory Bowel Disease

Enhanced recovery protocols apply:

• Preoperative fasting from midnight should not be performed 1
• Use ERAS (Enhanced Recovery After Surgery) protocols instead 1

Medication Management During NPO Status

Continue Essential Medications

Patients should take the following with small sips of water:

• Chronic medications for managing ongoing conditions 4
• Opioid agonists (to prevent withdrawal) 4
• Antihypertensives 4

Hold These Medications

Withhold on the morning of surgery:

• Oral hypoglycemic agents 4
• Metformin 4
• Opioid antagonists (alvimopan) 4

Fluid Management During NPO Status

Intravenous Fluid Support

For patients who must remain NPO:

• Administer maintenance IV fluids to prevent dehydration 2
• Use buffered crystalloid solutions over 0.9% saline 2
• Avoid excessive fluid administration 2

For stroke patients specifically:

• Provide maintenance IV fluids until dysphagia assessment is complete 2

Common Pitfalls to Avoid

Documentation Issues

When writing NPO orders, specify:

• Exact time restrictions (e.g., "NPO except clear liquids until 0600, then NPO") rather than vague "NPO after midnight" 5, 6
• Whether medications should be taken with sips of water 4
• Expected procedure time to guide nursing staff 6

Unnecessary NPO Orders

Avoid routine NPO for:

• Diagnostic imaging procedures not requiring sedation 6
• Minor procedures under local anesthesia 3
• Procedures scheduled late in the day (consider pre-procedure clear liquid diet) 1, 6

Prolonged Fasting Complications

Extended NPO periods cause:

• Patient discomfort, anxiety, and thirst 1
• Preoperative dehydration 3
• Increased postoperative insulin resistance 1
• Muscle catabolism in vulnerable populations (cirrhosis patients) 1

Implementation Strategy

To properly implement modern fasting guidelines:

1. Replace standing "NPO after midnight" orders with time-specific restrictions based on procedure timing 1, 6

2. Educate patients on the rationale for fasting requirements and permitted intake 7

3. Coordinate with anesthesia to confirm procedure start times and adjust NPO timing accordingly 6

4. Use pre-procedure clear liquid diet orders for procedures scheduled later in the day 6

5. Monitor compliance and aspiration events to ensure safety of liberalized protocols 6

The evidence demonstrates that aspiration risk is extremely low with modern anesthesia techniques, and prolonged fasting provides no benefit while causing patient harm through dehydration, discomfort, and metabolic stress 3, 6, 8.