Canceling a Case

An older gentleman who has multiple medical problems including insulin-dependent diabetes, amputations of both legs, dependence on a caretaker, and spinal stenosis presents for spinal surgery. In past anesthetic records, it's noted that he is a difficult intubation and has required multiple attempts and rescue techniques. When I meet him in the pre-operative area, however, I find out that he ate solid food for breakfast.

The reason why we have patients "NPO" (nil per os or nothing by mouth) before surgery is to reduce the risk of aspiration. If induction of anesthesia causes vomiting, a full stomach can go down the lungs, and that can be lethal. In cases where we cannot wait for a patient to be NPO, like an emergency trauma, we induce anesthesia and intubate as rapidly as possible. For this case, we were stuck against a rock and a hard place. The clear defensible obviously-correct answer is to delay the case until the requisite time is met. The risk of aspiration is unacceptable in someone who just ate solid food and is undergoing an elective surgery. We even considered doing the case with a rapid sequence induction, as if it were a trauma, but the history of difficult intubation makes that hardly ideal. We toyed around with the idea of an awake intubation, but that puts the patient through more discomfort than necessary.

The problem with delaying, however, is that the complexity of the case and the hardware needed makes daytime the best time to do the case. It was scheduled to be an incredibly long procedure and would need consultation with biomedical reps to get the appropriate equipment. Starting the case in the afternoon might mean the surgeons wouldn't have access to what they needed in the evening. They did not want to start the case that late, and so we had to cancel.

We do not cancel cases lightly. We fully recognized that this patient cannot leave his home independently, depends on his caretaker, and needs specialized transportation. Furthermore, adjustments to his medications on the day of surgery, especially insulin, makes his sugar and blood pressure management difficult in the case of a canceled operation. But after discussing all of this with the surgeon, the patient, and the caretaker, we decided to do what was right despite the inconvenience and disappointment to all involved.