Latest Ozempic Guidelines

[masterPain]

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I know this is a much debated topic and the guidelines have changed multiple times. Can someone kindly give me the latest? TIA

 

[aneftp]

There are no real general rules with ozempic. Just use your own best judgment.

If patient shows up and Iike general case. And you aren’t sure. Just rsi them.

The Mac cases are more the iffy choices.

 

[Radar26]

Follow your hospital’s policy. If that is gray, like ours, then for MAC case- I would tube them for the MAC case if they: recently started the drug (last 4 months), are on an escalating dose, have N/V symptoms, or what they recently ate.

I find it extremely rare to passively vomit during induction and quick intubation (as long as thy don’t cough or get stimulated when passing the tube). More often I hear about aspirations during MACs where the pt gets stimulated all a sudden…

 

[Gern Blansten]

The term “shared decision making” is key. I would explain risks to patient and allow them and their proceduralist to all be involved so that there is consensus and no surprises. Helps the communication flow better. But generally, as stated in above posts.

 

[NumTacos]

Agree with all of the above. Unless it is spelled out very precisely in your hospital policy, I tube most of these players.

 

[abolt18]

Our hospital policy says liquid diet x 24h if on GLP-1 for elective surgery. Patients doesn't follow that, they get the "X" and come back another day, hopefully following directions.

 

[Radar26]

Our hospital policy says liquid diet x 24h if on GLP-1 for elective surgery. Patients doesn't follow that, they get the "X" and come back another day, hopefully following directions.

I like that in theory- only issue is what liquids do they consume (yogurt, ice cream, fatty soups) and does that empty out of the stomach any faster?

Is it the consistency or the contents of what they ate that matters?

 

[PlayToWin]

Best policy at the moment is probably hold glp1 for 7 days and/or clear liquid for 24 hours. If mac and symptomatic for aspiration risk , then you’re in a bind. Maybe gastric ultrasound if you’re comfortable.

 

[aneftp]

Historically going back 35 years (1990 for those of you guys in practice at the time) . What were the phen phen anesthesia guidelines back at that time. (Not current anesthesia guidelines)

That’s what the ozempic guidelines feel like. We really don’t know.

 

[abolt18]

I like that in theory- only issue is what liquids do they consume (yogurt, ice cream, fatty soups) and does that empty out of the stomach any faster?

Is it the consistency or the contents of what they ate that matters?

ASA recommendation specifically says liquid diet x 24h and NPO x 8 hr like normal. Does not specify further than that.

 

[BLADEMDA]

FYI, I have had obese patients with DM who were off GLP1 meds for 1-2 weeks still have over 150 ml in residual gastric contents. One "aspirated" about 15 ml under GA with a proseal LMA. He still went home after 2 hours of observation in the PACU. I intubate more often and with a lower threshold on these types of patients regardless of any protocol in place.

 

[Mman]

One "aspirated" about 15 ml under GA with a proseal LMA.

how on earth did you verify and quantify a volume of "aspiration" with an LMA?

 

[Arch Guillotti]

FYI, I have had obese patients with DM who were off GLP1 meds for 1-2 weeks still have over 150 ml in residual gastric contents. One "aspirated" about 15 ml under GA with a proseal LMA. He still went home after 2 hours of observation in the PACU. I intubate more often and with a lower threshold on these types of patients regardless of any protocol in place.

Doesn't seem to be much of a point here.

 

[Maz777]

Here is the latest. Hot off the press. Published in the Journal of Table Up, Table Down.

• Do you dislike this particular surgeon and/or want to go home? Postpone case.
• Do you not care? Proceed.

I'll find the reference soon.

 

[Gern Blansten]

Here is the latest. Hot off the press. Published in the Journal of Table Up, Table Down.

• Do you dislike this particular surgeon and/or want to go home? Postpone case.
• Do you not care? Proceed.

I'll find the reference soon.

Now there is a Journal title I would like to see!

 

[Guillemot]

Gastric POCUS is a useful tool in making a determination upon anesthetic plan in questionable situations.

 

[Guillemot]

POCUS can solve the equivocation as to whether XXX meal is a light meal requiring six hours of fasting or eight hours. It still allows adherence toASA’s fasting guidelines, which is standard of care. However, we all know the ASA guidelines are somewhat ambiguous and open to interpretation in regard to the “light meal“. I’d say it’s worth the investment in learning it as it can make one’s life a lot easier rather than just winging it and hoping for the best vs unnecessarily, delaying the case

They’re still is the matter of optimizing patients prior to arrival, though and as far as I know, there is not a definitive standard of care for GLP1 agonists in that regard. I think most places heard of have rules of is either hold it 1-2 weeks or clear liquids for 24 hours. As long as the patient had followed those institutional rules, I would proceed forward with the case, but just taylor my anesthetic based on POCUS findings.

 

[dannyboy1]

Let’s make this real simple. If your patient aspirates, you were wrong. If not, you were correct. 😉
This is especially true if you used an LMA when you could have easily tubed. No jury is really going to want to get into the specifics when there is a catastrophe.

 

[pgg]

Gastric POCUS is a useful tool in making a determination upon anesthetic plan in questionable situations.

How so?

 

[pgg]

FYI, I have had obese patients with DM who were off GLP1 meds for 1-2 weeks still have over 150 ml in residual gastric contents. One "aspirated" about 15 ml under GA with a proseal LMA. He still went home after 2 hours of observation in the PACU. I intubate more often and with a lower threshold on these types of patients regardless of any protocol in place.

Maybe the best answer here is to never use LMAs in these patients.

Honestly, electively using a LMA in any case other than one in which you are confident about NPO status and the low risk of the case, doesn't make a lot of sense to me. Endotracheal tubes never let you down.

 

[Guillemot]

How so?

I gave examples in my second post

 

[pgg]

POCUS can solve the equivocation as to whether XXX meal is a light meal requiring six hours of fasting or eight hours. It still allows adherence toASA’s fasting guidelines, which is standard of care. However, we all know the ASA guidelines are somewhat ambiguous and open to interpretation in regard to the “light meal“. I’d say it’s worth the investment in learning it as it can make one’s life a lot easier rather than just winging it and hoping for the best vs unnecessarily, delaying the case

They’re still is the matter of optimizing patients prior to arrival, though and as far as I know, there is not a definitive standard of care for GLP1 agonists in that regard. I think most places heard of have rules of is either hold it 1-2 weeks or clear liquids for 24 hours. As long as the patient had followed those institutional rules, I would proceed forward with the case, but just taylor my anesthetic based on POCUS findings.

I see where you're coming from, and commend you for not wanting to unnecessarily delay a case.


But the easy button is just to require 8 hours in these vague light-vs-full meal edge cases. I'm not the one who ate. They all know the rules. They can wait or come back another day.

As for using POCUS to guide your anesthetic plan for patients taking a GLP1 - unless it's a GI case, I just put tubes in all of these patients now, even if they've held the drug for the recommended period.

What's the benefit of gastric u/s there? To support using a LMA instead of a tube? To not delay or cancel an elective case after a NPO violation?

 

[gunnershow]

I see where you're coming from, and commend you for not wanting to unnecessarily delay a case.


But the easy button is just to require 8 hours in these vague light-vs-full meal edge cases. I'm not the one who ate. They all know the rules. They can wait or come back another day.

As for using POCUS to guide your anesthetic plan for patients taking a GLP1 - unless it's a GI case, I just put tubes in all of these patients now, even if they've held the drug for the recommended period.

What's the benefit of gastric u/s there? To support using a LMA instead of a tube? To not delay or cancel an elective case after a NPO violation?

Why not tube for a colonoscopy on a GLP1? Because it's annoying? Same reason I don't want to tube other sedation cases like TEE, ECV, hand surgery, ESWLs, etc