07:10 Add-On Pressure: The Crackers at 0300
07:10. The first case is a 58-year-old woman scheduled for elective laparoscopic cholecystectomy at 07:30 for symptomatic cholelithiasis. In preop holding she volunteers that she "had a few crackers and some juice around 3 this morning" because she felt shaky. The chart reads "NPO after midnight." Point-of-care glucose is 262 mg/dL; she held her metformin today, and last week's A1c was 9.4%. Consent is signed and witnessed and lists "lap chole." The room is set up, the video tower is on, and no antibiotic has been hung. The surgeon is starting another case and tells the circulator by phone, "She's fine. Bring her back, we'll be quick."
1. The patient reports eating at 03:00 and the surgeon is pushing to proceed. What do you do, and whose decision is this?
Read the worked answer
Act on it immediately and on the record. The decision is not the surgeon's alone.
- Report the exact content to the anesthesia professional and the circulator before induction: what she ate, how much, what time, and that it was unplanned.
- Apply the ASA fasting intervals: light meal 6 hours, fatty/fried meal 8 hours, clear liquids 2 hours. 03:00 + 6 hours puts the earliest defensible start around 09:00, and a self-reported unplanned snack in a symptomatic patient is a reliability problem, not just arithmetic. She was shaky at 03:00, which raises a glucose-handling question for anesthesia.
- Fasting status is the anesthesia professional's determination. A phone instruction from a surgeon in another room cannot override it, and "we'll be quick" is not a risk assessment. Say it neutrally, in front of the circulator, and let anesthesia document the decision.
- If pushed, escalate: charge nurse, then the anesthesia medical director and the surgeon. Never soften or omit the intake in the record. Do not pull the IV or start transport until the decision is documented.
- Your duty is patient advocacy plus an accurate record, not to cancel the case unilaterally and not to stay silent.
2. Anesthesia clears her for a 09:15 start. What are your next steps, and when exactly must the antibiotic be given?
Read the worked answer
Antibiotic timing is a stopwatch problem, not a checkbox.
- Confirm the order and the allergy history (what kind of penicillin reaction, if any) and the weight documented today. For a penicillin-tolerant adult under 120 kg, cefazolin 2 g IV; 3 g if 120 kg or more.
- The infusion must be completed within 60 minutes before incision (and not started earlier than 120 minutes before). With a 09:15 start, hang so it finishes between 08:15 and 09:15.
- Plan the redose now: cefazolin every 4 hours intraoperatively or after roughly 1500 mL estimated blood loss. Note the case may be longer than usual with a delayed start.
- Report the glucose of 262 mg/dL with an A1c of 9.4% to both the surgeon and anesthesia. Perioperative hyperglycemia raises surgical site infection risk, and many institutions require a value under roughly 180 to 200 mg/dL before elective incision. That is a second, independent reason the case might be delayed, and it belongs in the conversation before induction.
- Finish the routine preop verification in parallel: consent matches the procedure, H&P is current, VTE prophylaxis is ordered, intraoperative cholangiogram equipment is available if requested, and warming and positioning supplies are ready.