NPO Guidelines

Updated: 
July 4, 2024
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NPO Guidelines

NPO (Nil Per Os) Status refers to the medical instruction to withhold oral intake of food and fluids. It is commonly required before surgeries or certain medical tests to minimize the risk of aspiration and other complications. NPO guidelines often specify different levels of restriction, including clear liquids, milk, and full liquids.

General NPO Guidelines:

  1. Clear Liquids:
    • Definition: Clear liquids are easily digestible fluids that leave little residue in the digestive tract.
    • Examples: Water, clear broths, apple juice, cranberry juice, tea, coffee (without milk/cream), sports drinks, and gelatin.
    • Timing: Clear liquids are typically allowed up to 2 hours before surgery or a procedure.
  2. Full Liquids:
    • Definition: Full liquids include all clear liquids plus additional options that are liquid or semi-liquid at room temperature.
    • Examples: Milk, milkshakes, ice cream, cream soups, pudding, and yogurt.
    • Timing: Full liquids are generally restricted starting 6 hours before surgery or a procedure.
  3. Solid Foods:
    • Definition: This category includes any food that is solid or requires chewing.
    • Timing: Solid foods should generally be avoided starting 8 hours before surgery or a procedure.
  4. Specific Guidelines for Different Types of Liquids:
    • Clear Liquids: Allowed up to 2 hours before anesthesia.
      • Examples: Water, apple juice, black coffee, tea.
    • Breast Milk: Allowed up to 4 hours before anesthesia.
    • Infant Formula: Allowed up to 6 hours before anesthesia.
    • Non-Human Milk: Allowed up to 6 hours before anesthesia.
    • Light Meals: Typically includes toast and clear liquids, allowed up to 6 hours before anesthesia.
    • Full Meals: Includes fatty or fried foods, should be avoided at least 8 hours before anesthesia.

Special Considerations:

  • Medications:
    • Most medications can be taken with a small sip of water unless otherwise instructed by the healthcare provider.
    • Specific instructions should be provided for medications like insulin or blood thinners.
  • Hydration:
    • Adequate hydration with clear liquids is important to prevent dehydration. Follow specific guidelines provided by the healthcare provider.

Postoperative Considerations:

  • Resuming Diet:
    • Patients are usually allowed to resume clear liquids first, followed by a gradual progression to full liquids and then solid foods, based on their tolerance and medical advice.

Anesthesia

  • ​Cumulative Anesthetic (Off Service Anesthesia+ OMFS) Experience:
  • general anesthesia/deep sedation for a minimum of 300 cases.
  • Must involve care for 50 patients younger than 13.
  • A minimum of 150 of the 300 cases must be ambulatory anesthetics for oral and maxillofacial surgery outside of the operating room.

Major Surgery

  • Final Year Requirement:
  • 175 major oral and maxillofacial surgery procedures on adults and children, documented by at least a formal operative note.
  • For the above 175 procedures there must be at least 20 procedures in each category of surgery. Sufficient variety in each category, as specified below, must be provided.
  • The categories of major surgery are defined as: Trauma, Pathology, Orthognathic Surgery, Reconstructive and Cosmetic Surgery
  • Surgery performed by oral and maxillofacial surgery residents while rotating on or assisting with other services must not be counted toward this requirement
  • ​​Surgical procedures performed during foreign rotations must not count toward fulfillment of the 175 major surgical procedures.

Research

  • Oral or poster presentations at scientific meetings aside from program curriculum
  • Submission for publication of abstracts, journal articles (particularly peer reviewed) or book chapters
  • Active participation in or completion of a research project (basic science or clinical) with mentoring

Certifications

  • ACLS maintained throughout residency
  • PALS- certified during residency
  • ATLS- certified during residency

Accepted Codes by Category:

Select Surgical Category

Cleft

Alveolar

  • 42205, 42210

Lip

  • 40700, 40701, 40702, 40720, 40761, 42260

Palate

  • ​42200, 42215, 42220, 42225, 42226, 42227, 42235, 42950

Craniofacial

Osteotomies

  • 21137, 21138, 21139, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21260, 21261, 21263, 21267, 21268, 21275, 61557, 61559

Esthetic

Augmentation/Reduction Surgery

  • 21120, 21125, 21127, 21208, 21209, 21270

Chemodenervation

  • 64612

Fillers

  • 11950, 11951, 11952, 11954

Soft Tissue Facial Non-Surgical

  • 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 17004, 17106, 17107, 17108

Soft Tissue Facial Surgical

  • 15819, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15876, 67900, 67901, 69300

Rhinoplasty

  • ​15760, 21235, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520

Infection

Major

  • 10061, 10121, 10140, 10180, 40801, 41005, 41006, 41007, 41008, 41009, 41015, 41016, 41017, 41018, 42300, 42305, 42310, 42320, 42700, 42720, 42725

Minor

  • 10060, 10120, 10160, 21501, 40800, 41000, 41800, 41805, 41806

Orthognathic

Genioplasty Osteotomies

  • 21121, 21122, 21123

Mandibular Osteotomies

  • 21193, 21194, 21195, 21196, 21198, 21199

Maxillary Osteotomies

  • ​21141, 21142, 21143, 21145, 21146, 21147, 21188, 21206

Pathology

Biopsies

  • 11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 20240, 20245, 21550, 40490, 40808, 41100, 41105, 41108, 42100,42400, 42405

Lesion Excision/Resection Bone Benign

  • 20615, 21025, 21026, 21029, 21030, 21040, 21046, 21047, 21048, 21049, 21295, 21296, 41825, 41826, 41827, 41850

Lesion Excision/ Resection Malignant

  • 11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641, 11642, 11643, 11644, 11646, 17270, 17272, 17273, 17274, 17276, 17280, 17281, 17282, 17283, 17284, 17286, 21015, 21034, 21044, 21045, 21557, 40500, 40510, 40520, 40530, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155

Lesion Excision/Resection Soft Tissue Extraoral/Benign

  • 11420, 11421, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 17000, 17110, 21555, 42810, 42815

Lesion Excision/Resection Soft Tissue Intraoral/Benign

  • 40810, 40812, 40814, 40816, 40820, 41110, 41112, 41113, 41114, 41116, 42104, 42106, 42107, 42120

Salivary Gland

  • 42330, 42335, 42408, 42409, 42410, 42415, 42420, 42425, 42426, 42440, 42450

Sinus

  • 30580, 31030, 31032

Preprosthetic

Implants

  • 21244, 21245, 21246, 21248, 21249, D6010

Preprosthetic Surgery

  • 40840, 40842, 40843, 40844, 40845, 41822, 41823, D4263

Preprosthetic Surgery Soft Tissue

  • 40818, D4273, D4275, D4276, D4277, D4278

Reconstruction

Cartilage Grafting

  • 20912, 21230

Major Bone Grafting Free Bone Grafting

  • 20969, 20970, 20972, 21210, 21215

Microvascular

  • 15757, 20955, 20956, 20957, 20962

Nerve Surgery

  • 64716, 64732, 64734, 64736, 64738, 64742, 64885, 64886

Salivary Duct

  • 42500, 42505, 42507, 42509, 42510, 42665

Soft Tissue Flap Local/Adjacent

  • 14020, 14021, 14040, 14041, 14060, 14061

Soft Tissue Flap Regional/Nearby

  • 15572, 15574, 15576, 15610, 15620, 15630, 15732, 40525, 40527

Soft Tissue Graft Free Skin Grafting

  • 15120, 15121, 15220, 15221, 15240, 15241, 15260, 15261, 15770

Temporomandibular Joint

Arthroscopy

  • 29800, 29804

Minimally Invasive

  • 20605, 21480, 21485

Open Joint

  • 21010, 21050, 21060, 21070, 21240, 21242, 21490

Reconstructive Autogenous

  • 20910

Reconstructive Prothetic

  • 21243

Tracheostomy

Tracheostomy

  • 31600, 31601, 31603, 31605, 31610

Trauma

Dentoalveolar Trauma

  • 21440, 21445, D7270

Mandible Fractures

  • 21450, 21451, 21452, 21453, 21454, 21461, 21462, 21465, 21470

Midface/Upper Face Fractures, Frontal Sinus Fractures

  • 21343, 21344

Midface/Upper Face Fractures, LeFort Fractures

  • 21345, 21346, 21347, 21348, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436

Midface/Upper Face Fractures, Malar Fractures

  • 21356, 21360, 21365, 21366

Midface/Upper Face Fractures, Nasal Fractures

  • 21310, 21315, 21320, 21325, 21330, 21335, 21336, 21337, 30020

Midface/Upper Face Fractures, NOE Fractures

  • 21338, 21339, 21340

Midface/Upper Face Fractures, Orbital Fractures

  • 21280, 21282, 21385, 21386, 21387, 21390, 21395, 21400, 21401, 21406, 21407, 21408

Repair of Lacerations Extraoral

  • ​12001, 12002, 12004, 12005, 12006, 12007, 12011, 12013, 12014, 12015, 12016, 12017, 12018, 12031, 12032, 12034,12035, 12036, 12037, 12041, 12042, 12044, 12045, 12046, 12047, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 40650, 40652, 40654, 40830, 40831

Repair of Lacerations Intraoral

  • 41250, 41251, 41252, 42180
Select Drug Category

Lidocaine (Xylocaine):   - Maximum Dose without Epinephrine: 4.5 mg/kg (without epinephrine)   - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine)   - Toxicity: Symptoms of lidocaine toxicity may include dizziness, confusion, seizures, cardiovascular collapse, and cardiac arrest.

Bupivacaine (Marcaine):   - Maximum Dose without Epinephrine: 2 mg/kg (without epinephrine)   - Maximum Dose with Epinephrine: 3 mg/kg (with epinephrine)   - Toxicity: Bupivacaine toxicity can cause significant cardiotoxicity, leading to cardiac arrhythmias, cardiac arrest, and central nervous system (CNS) effects such as seizures and dizziness.

Mepivacaine (Carbocaine):   - Maximum Dose without Epinephrine: 4.5 mg/kg (without epinephrine)   - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine)   - Toxicity: Symptoms of mepivacaine toxicity are similar to other local anesthetics and may involve CNS and cardiovascular effects.

Procaine (Novocaine):   - Maximum Dose without Epinephrine: 7 mg/kg (without epinephrine)   - Maximum Dose with Epinephrine: Not typically used with epinephrine   - Toxicity: Procaine toxicity may present with symptoms similar to other local anesthetics but is less frequently used today due to its shorter duration and higher allergenic potential.

Articaine (Septocaine):   - Maximum Dose without Epinephrine: 7 mg/kg (without epinephrine)   - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine)   - Toxicity: Articaine has a longer duration of action but can cause similar toxicity symptoms as other local anesthetics if administered excessively or if there's accidental intravascular injection.

Select an Electrolyte

Hypokalemia (Low Potassium Levels):  

- Mild to Moderate Hypokalemia (3.0-3.5 mEq/L):    

- Oral potassium supplementation: Potassium chloride tablets or liquid, 20-40 mEq orally per day in divided doses.  

- Severe Hypokalemia (<3.0 mEq/L):    

- IV potassium chloride: Start with 10-20 mEq/hour, under continuous cardiac monitoring.

Hyperkalemia (High Potassium Levels):  

- Mild Hyperkalemia (5.1-6.0 mEq/L):    

- Dietary potassium restriction and discontinuation of potassium supplements.  

- Severe Hyperkalemia (>6.0 mEq/L or with ECG changes):    

- Calcium gluconate or calcium chloride IV to stabilize cardiac membranes.    

- Insulin with glucose IV, beta-agonists (e.g., albuterol), or sodium bicarbonate to shift potassium into cells.     - Loop diuretics or exchange resins (e.g., sodium polystyrene sulfonate) to enhance potassium removal.

Hypocalcemia (Low Calcium Levels):  

- Mild Hypocalcemia (8.0-8.5 mg/dL):    

- Oral calcium supplements: Calcium carbonate or calcium citrate, doses vary based on elemental calcium content.  

- Severe Hypocalcemia (<8.0 mg/dL or symptomatic):    

- IV calcium gluconate or calcium chloride, dosages depend on severity and symptoms.

Hypercalcemia (High Calcium Levels):  

- Mild Hypercalcemia (10.5-11.9 mg/dL):    

- Hydration with IV saline and loop diuretics.  

- Severe Hypercalcemia (>12 mg/dL or symptomatic):    

- Bisphosphonates, calcitonin, or corticosteroids may be used for severe cases.

Hypomagnesemia (Low Magnesium Levels):  

- Mild to Moderate Hypomagnesemia (1.2-1.8 mg/dL):    

- Oral magnesium supplements: Magnesium oxide, magnesium citrate, or magnesium glycinate, dosages vary.  

- Severe Hypomagnesemia (<1.2 mg/dL or symptomatic):    

- IV magnesium sulfate, doses vary based on severity and response.

Hypermagnesemia (High Magnesium Levels):  

- Mild to Moderate Hypermagnesemia (2.5-3.0 mg/dL):    

- Discontinuation of magnesium-containing medications.  

- Severe Hypermagnesemia (>3.0 mg/dL or with symptoms):    

- IV calcium gluconate for severe symptoms.    

- Dialysis may be necessary in extreme cases.

Select Surgical Category
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American Society of Anesthesiologists. (2017). Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology, 126(3), 376-393. DOI: 10.1097/ALN.0000000000001452