C’mon, ASA

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the cliff notes answer to their “guidelines “ is “we really don’t know what the F we want to recommend”

That’s the honest truth.

It’s absolute garbage what guidance they are giving between the GI docs and anesthesia society and the obesity society.

They answer the questions how Supreme Court nominees answer questions how they would vote in particular cases. With non answers

To sum it up
“Proceed with your own best judgment”
 
aneftp said:
the cliff notes answer to their “guidelines “ is “we really don’t know what the F we want to recommend”

That’s the honest truth.

It’s absolute garbage what guidance they are giving between the GI docs and anesthesia society and the obesity society.

They answer the questions how Supreme Court nominees answer questions how they would vote in particular cases. With non answers

To sum it up
“Proceed with your own best judgment”
Click to expand...

They caved like a bunch of ******* when faced with a little pushback from a bunch of GIs and surgeons.

Skipping a pill for a day or an injection for a week is a very easy intervention. If you have to hold a million doses to see a statistically significant risk reduction it’s worth it IMO. Especially when the vast majorities patients are in these medications to lose some weight.
 
I have seen patients who did not hold the med (for emergent cases) have vomiting on induction and have a ton of crap suctioned out from the OG tube. I would not want to do an elective case on a patient who did not hold a dose of the medication
 
Seems ultimately pretty straightforward.

Hold for 7 days then proceed

If they don't hold, then liquid diet 24 hrs and proceed

If they don't do either, then cancel or RSI

Patients shouldn't be aspirating if they are head up, paralyzed and then intubated. Not enough positive abdominal pressure to push material up the esophagus. Unless they are massively obese or unusual scenario.
 
UscGhost said:
Seems ultimately pretty straightforward.

Hold for 7 days then proceed

If they don't hold, then liquid diet 24 hrs and proceed

If they don't do either, then cancel or RSI

Patients shouldn't be aspirating if they are head up, paralyzed and then intubated. Not enough positive abdominal pressure to push material up the esophagus. Unless they are massively obese or unusual scenario.
Click to expand...
Where does this article say to hold for 7 days?
 
okayplayer said:
Where does this article say to hold for 7 days?
Click to expand...
If the decision to hold GLP-1RAs is indicated given an unacceptable safety profile following shared decision-making in the preoperative period, the duration to hold therapy is unknown [7]. At this time, it is suggested to follow the original guidance of the American Society of Anesthesiologists, holding the day of surgery for daily formulations, and a week prior to surgery for weekly formulations [4]. All patients should still be assessed on the day of procedure for symptoms suggestive of delayed gastric emptying.


Going to be very difficult to personalize pre-op recommendations for each patient based on all of those qualifiers, assess risk of delayed gastric emptying, etc. Pre op care teams?? Where do those exist in PP

So I guess an additional option is to not hold and just have all of those patients be liquid diet 24 hrs.
 
UscGhost said:
If the decision to hold GLP-1RAs is indicated given an unacceptable safety profile following shared decision-making in the preoperative period, the duration to hold therapy is unknown [7]. At this time, it is suggested to follow the original guidance of the American Society of Anesthesiologists, holding the day of surgery for daily formulations, and a week prior to surgery for weekly formulations [4]. All patients should still be assessed on the day of procedure for symptoms suggestive of delayed gastric emptying.


Going to be very difficult to personalize pre-op recommendations for each patient based on all of those qualifiers, assess risk of delayed gastric emptying, etc. Pre op care teams?? Where do those exist in PP

So I guess an additional option is to not hold and just have all of those patients be liquid diet 24 hrs.
Click to expand...
The problem I have with the 24 hr liquid diet is it sounds like a specific carve out for the GI docs so they can still get their colons done under “mac” without holding meds (they are on a prep anyway).
 
DocMcCoy said:
The problem I have with the 24 hr liquid diet is it sounds like a specific carve out for the GI docs so they can still get their colons done under “mac” without holding meds (they are on a prep anyway).
Click to expand...
Possibly.

But I also never saw any actual data showing increased aspiration events.
 
UscGhost said:
Possibly.

But I also never saw any actual data showing increased aspiration events.
Click to expand...
I think you are correct. It is all anecdotal, but I don't think anyone has studied it. I don't think the headline of the article corresponds at all with the source article and only mildly corresponds to the letter to the editor by Joshi et al.
This new source paper offers zero new science as best I can tell and the source paper that was multidisciplinary states that, if you have concerns, follow the original guidelines. The only bit of new information (which I already knew) is that high dose is likely a greater risk for delayed gastric emptying than the low dose for the drugs and that people who are new to the drug may be at a slightly higher risk.
As stated by others, we finally were getting some buy in on the issue and getting surgeons and GI docs to have their patients hold the meds. Now they wish for us to risk stratify them on all of these levels. The only ones who will see the patient in a timely manner to be able to risk stratify them will be the ones who are least willing or qualified to do so.
So, this new set of recommendations feels a lot like the old ones but with a little more freedom to not just cancel the patient if everyone is in agreement to go ahead. It may lead to a lot of patients getting ETT for screening colonoscopy and will likely lead to some complacency that will result in a few cases of aspiration.
The headline makes it sound as if they have new information and they are walking back the recommendations and no longer have concerns. I don't see that as the case at all.
We are trying to figure out a response to this at our place. It is a new headache that we should not have because, if you don't have new information, why are you making any new recommendations? It is not as if the original problem no longer exists.
 
Gern Blansten said:
I think you are correct. It is all anecdotal, but I don't think anyone has studied it. I don't think the headline of the article corresponds at all with the source article and only mildly corresponds to the letter to the editor by Joshi et al.
This new source paper offers zero new science as best I can tell and the source paper that was multidisciplinary states that, if you have concerns, follow the original guidelines. The only bit of new information (which I already knew) is that high dose is likely a greater risk for delayed gastric emptying than the low dose for the drugs and that people who are new to the drug may be at a slightly higher risk.
As stated by others, we finally were getting some buy in on the issue and getting surgeons and GI docs to have their patients hold the meds. Now they wish for us to risk stratify them on all of these levels. The only ones who will see the patient in a timely manner to be able to risk stratify them will be the ones who are least willing or qualified to do so.
So, this new set of recommendations feels a lot like the old ones but with a little more freedom to not just cancel the patient if everyone is in agreement to go ahead. It may lead to a lot of patients getting ETT for screening colonoscopy and will likely lead to some complacency that will result in a few cases of aspiration.
The headline makes it sound as if they have new information and they are walking back the recommendations and no longer have concerns. I don't see that as the case at all.
We are trying to figure out a response to this at our place. It is a new headache that we should not have because, if you don't have new information, why are you making any new recommendations? It is not as if the original problem no longer exists.
Click to expand...
Agreed.

The original recommendations seemed to be made too quickly and without data...and now we are stuck. The new recs aren't very practical

We gets a lot of patients who are 5 days, 6 days off. I try not to cancel as it seems very wasteful, and detrimental for cancer cases, etc. So at least this can give us the alternative of liquid diet 24hrs instead of cancelling someone who has been off it for 5 days
 
Get used to doing gastric ultrasounds. Not sure how feasible this is but it’s all I can do to confirm stomach contents. NO one will fight you if you see food in stomach and cancel - specifically for patients on glp-1A.

Alternatively, if patient has had aspiration history , you’re not cancelling, you’re most likely RSI with Ett.
 
One of my partners noticed this gem of a statement from the ASA -

www.asahq.org

Most Patients Can Continue Diabetes, Weight Loss GLP-1 Drugs Before Surgery, Those at Highest Risk for GI Problems Should Follow Liquid Diet Before Procedure

Most patients should continue taking their glucagon-like peptide-1 (GLP-1) receptor agonists before elective surgery, suggests new clinical guidance released by the American Society of Anesthesiologists (ASA), American Gastroenterological Association, American Society for Metabolic and Bariatric...
www.asahq.org www.asahq.org

Further, the guidance notes withholding GLP-1 drugs only for obese and overweight patients could constitute bias or discrimination and should be avoided.
Click to expand...

I mean, I get what they're saying, but common ASA.

I mean c'mon.
 
pgg said:
One of my partners noticed this gem of a statement from the ASA -

www.asahq.org

Most Patients Can Continue Diabetes, Weight Loss GLP-1 Drugs Before Surgery, Those at Highest Risk for GI Problems Should Follow Liquid Diet Before Procedure

Most patients should continue taking their glucagon-like peptide-1 (GLP-1) receptor agonists before elective surgery, suggests new clinical guidance released by the American Society of Anesthesiologists (ASA), American Gastroenterological Association, American Society for Metabolic and Bariatric...
www.asahq.org www.asahq.org



I mean, I get what they're saying, but common ASA.

I mean c'mon.
Click to expand...
I saw that. It’s a ridiculous thing to put in a so-called scientific statement.
 
WTF? Don’t treat the morbidly obese differently because that might be considered bias or discriminatory? They’re fat with actual medical problems and special concerns directly related to their morbid obesity. Thats not bias, it’s reality. Who TF is writing this, some communication major from the community college?
 
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IlDestriero said:
WTF? Don’t treat the morbidly obese differently because that might be considered bias or discriminatory? They’re fat with actual medical problems and special concerns directly related to their morbid obesity. Thats not bias, it’s reality. Who TF is writing this, some communication major from the community college?
Click to expand...
It’s like saying that we shouldn’t treat cancer patients with appropriate treatments because we don’t want to hurt their feelings by acknowledging that they have cancer.
 
ASA disappoints yet again

"this multisociety consensus provides guidance for management of patients on GLP-1RAs; however, it is NOT an evidence-based guideline."

Great.
So no data to actually support this change.

This about-face reinterpretation gives surgeons and other proceduralists weight to push cases forward, without reading the fine-print and nuances of this consensus.
 
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UscGhost said:
At this time, it is suggested to follow the original guidance of the American Society of Anesthesiologists, holding the day of surgery for daily formulations, and a week prior to surgery for weekly formulations
Click to expand...

The way I read this originally is you skip your weekly dose AND THEN wait a week, which means waiting two weeks since last injection. .
 
Wow, that’s really surprising. I’m wondering what transpired to have them change their stance.
 
Iso4ane said:
The way I read this originally is you skip your weekly dose AND THEN wait a week, which means waiting two weeks since last injection. .
Click to expand...
Interesting.

Is that the common way to read that?
 
aneftp said:
the cliff notes answer to their “guidelines “ is “we really don’t know what the F we want to recommend”

That’s the honest truth.

It’s absolute garbage what guidance they are giving between the GI docs and anesthesia society and the obesity society.

They answer the questions how Supreme Court nominees answer questions how they would vote in particular cases. With non answers

To sum it up
“Proceed with your own best judgment”
Click to expand...
In my judgement I’m cancelling the anesthetic not the procedure; but if GI thinks it’s low risk and wants to proceed I’m not going to stop them.
 

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UscGhost said:
Seems ultimately pretty straightforward.

Hold for 7 days then proceed

If they don't hold, then liquid diet 24 hrs and proceed

If they don't do either, then cancel or RSI

Patients shouldn't be aspirating if they are head up, paralyzed and then intubated. Not enough positive abdominal pressure to push material up the esophagus. Unless they are massively obese or unusual scenario.
Click to expand...
This is the correct way of intubating everyone, every time. Outside of the “maintain spontaneous ventilation” scenarios.

Every intubation. Head up, induction->paralytic-> tube. No masking unless you miss. KISS. And keep what’s in the stomach in the stomach.
 
OB1🤙 said:
This is the correct way of intubating everyone, every time. Outside of the “maintain spontaneous ventilation” scenarios.

Every intubation. Head up, induction->paralytic-> tube. No masking unless you miss. KISS. And keep what’s in the stomach in the stomach.
Click to expand...
Are you giving succ to everyone then? That's cruel.

I mask almost everyone because I give roc to almost everyone, and it takes a minute or so to work.

Masking doesn't really risk insufflating the stomach and creating an aspiration risk unless the patient is huge / bearded and edentulous / has an otherwise bad airway ... or if you suck at masking. 🙂
 
pgg said:
Are you giving succ to everyone then? That's cruel.

I mask almost everyone because I give roc to almost everyone, and it takes a minute or so to work.

Masking doesn't really risk insufflating the stomach and creating an aspiration risk unless the patient is huge / bearded and edentulous / has an otherwise bad airway ... or if you suck at masking. 🙂
Click to expand...
No. Rarely use sux. Especially since sugammadex is available, much easier to use Roc for short cases. Don't want sux myalgia.

Prop, Roc, fent. Usual. I don't wait full time, intubation conditions good enough unless I am too light on the property.

But yes, mask sometimes but not high pressures. Even then, you would have to mask for a long time to insufflated the stomach that much
 
pgg said:
Are you giving succ to everyone then? That's cruel.

I mask almost everyone because I give roc to almost everyone, and it takes a minute or so to work.

Masking doesn't really risk insufflating the stomach and creating an aspiration risk unless the patient is huge / bearded and edentulous / has an otherwise bad airway ... or if you suck at masking. 🙂
Click to expand...


Funny. I give roc to almost everyone too but almost never mask anyone. But I do glidescope just about everyone. I think you don’t really need complete relaxation (or as much induction agent) to intubate with a glidescope compared to DL. I RSI everyone and ask them to open their eyes. If they don’t, I go in with the glidescope and intubate. Once in a while I see the cords still quivering but I advance the tube when they’re open.

Agree that masking when properly performed doesn’t significantly increase risk of aspiration.
 
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pgg said:
Are you giving succ to everyone then? That's cruel.

I mask almost everyone because I give roc to almost everyone, and it takes a minute or so to work.

Masking doesn't really risk insufflating the stomach and creating an aspiration risk unless the patient is huge / bearded and edentulous / has an otherwise bad airway ... or if you suck at masking. 🙂
Click to expand...
Only time I ever give sux is in ECT. Completely agree it’s cruel.
 
pgg said:
Are you giving succ to everyone then? That's cruel.

I mask almost everyone because I give roc to almost everyone, and it takes a minute or so to work.

Masking doesn't really risk insufflating the stomach and creating an aspiration risk unless the patient is huge / bearded and edentulous / has an otherwise bad airway ... or if you suck at masking. 🙂
Click to expand...
I don’t mask during that minute. I just stand there and chat up the room.
 
Arch Guillotti said:
How about a recent full meal for an emergency case. History of previous aspiration and also gastroparesis?
Click to expand...
Probably not. Back up, lots and lots of roc. But I wouldn’t fault anyone for giving it in that scenario.

If intragastric pressure isn’t high (as in SBO) and the glottis is well above the stomach and the patient is paralyzed, I think you’re good.
 
Sux is cruel? Since when? I hardly use it (maybe [emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6]]]][emoji[emoji6][emoji6]][emoji[emoji[emoji6]][emoji[emoji6][emoji6]]]]] times a year), but not because I think it’s cruel, I just don’t like the myalgias, and all the other side effects.
 
The timing of this FDA advisory stating GLP1 meds may cause pulmonary aspiration during deep sedation and GA is certainty interesting given the ASA's determination that there's not enough information to make a recommendation, lol.

www.webmd.com

New FDA Warning Added to Popular Weight Loss Drugs

www.webmd.com www.webmd.com

Nov. 6, 2024 – The FDA has updated the labels for all GLP-1 weight loss drugs with a warning about pulmonary aspiration during general anesthesia or deep sedation. The affected drugs are liraglutide (Saxenda, Victoza), semaglutide (Ozempic, Rybelsus, Wegovy), and tirzepatide (Mounjaro, Zepbound).

“This was a safety-related labeling change for the glucagon-like peptide-1 receptor agonist product class,” an FDA spokesperson said.
 
psycho-matic said:
The timing of this FDA advisory stating GLP1 meds may cause pulmonary aspiration during deep sedation and GA is certainty interesting given the ASA's determination that there's not enough information to make a recommendation, lol.

www.webmd.com

New FDA Warning Added to Popular Weight Loss Drugs

www.webmd.com www.webmd.com

Nov. 6, 2024 – The FDA has updated the labels for all GLP-1 weight loss drugs with a warning about pulmonary aspiration during general anesthesia or deep sedation. The affected drugs are liraglutide (Saxenda, Victoza), semaglutide (Ozempic, Rybelsus, Wegovy), and tirzepatide (Mounjaro, Zepbound).

“This was a safety-related labeling change for the glucagon-like peptide-1 receptor agonist product class,” an FDA spokesperson said.
Click to expand...
Fake news!! ASA says it’s safe!!
 
Yeah I’m curious about this as well. I try to avoid sux especially if they are very young. I give defasiculating dose and lidocaine to help reduce myalgia when I use sux but I don’t follow up on my patients. How bad is myalgia ? I’ve heard that it can be pretty terrible.
 
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