Low Rate of Aspiration With GLP-1s During Upper GI Endoscopy

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TheLoneWolf

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How are different places handling "macs" for patients on GLP-1 agonists?

American Gastroenterological Association says no data to support stopping these meds prior to endoscopic procedures.

Ortho is hopping on board and demanding patients don't stop the med and want spinals with heavy "macs". Also insist of patients drinking large volume electrolyte solutions right up to the 2 hour mark.

Is the only way around this to get real good at bedside gastric ultrasound interpretation and make a determination obased solely on that?

I would much prefer we stick to our guidelines and ignore the Non-anesthetic recommendations. Analogous to Emergency Medicine guidelines saying it's safe to sedate nonfasted patients for procedures.

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How are different places handling "macs" for patients on GLP-1 agonists?

American Gastroenterological Association says no data to support stopping these meds prior to endoscopic procedures.

Ortho is hopping on board and demanding patients don't stop the med and want spinals with heavy "macs". Also insist of patients drinking large volume electrolyte solutions right up to the 2 hour mark.

Is the only way around this to get real good at bedside gastric ultrasound interpretation and make a determination obased solely on that?

I would much prefer we stick to our guidelines and ignore the Non-anesthetic recommendations. Analogous to Emergency Medicine guidelines saying it's safe to sedate nonfasted patients for procedures.

System wide we’re following ASA guidelines for these meds. Cases can and are being cancelled/rescheduled for not following ASA guidelines/hold parameters for GLP agonists. If Ortho or GI or EM want to sedate their own patients, they can follow their own society guidelines.

Anesthesia is a scarce resource these days. If they want our help they gotta play by our rules (emergencies aside, obviously).
 
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Having covered multiple private Gi centers in my career…it comes down to profit.

Read the statement closely. The Gi docs don’t even know what their own guidelines should be since there is no data

But many gi docs readily admit propofol deep sedation increases risk of colon perforation since no patient feed back

The simplest solution for the asa if they had the balls is to just let gi docs sedation own patients under moderate sedation if under ozempic/monjaro if anesthesia doesn’t want to do it.

Anesthesia gets $0 so no skin off their back. ….oh wait. Gi docs get 50% of anesthesia profits and assume liability.
 
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System wide we’re following ASA guidelines for these meds. Cases can and are being cancelled/rescheduled for not following ASA guidelines/hold parameters for GLP agonists. If Ortho or GI or EM want to sedate their own patients, they can follow their own society guidelines.

Anesthesia is a scarce resource these days. If they want our help they gotta play by our rules (emergencies aside, obviously).

You hiring?
 



How are different places handling "macs" for patients on GLP-1 agonists?

American Gastroenterological Association says no data to support stopping these meds prior to endoscopic procedures.

Ortho is hopping on board and demanding patients don't stop the med and want spinals with heavy "macs". Also insist of patients drinking large volume electrolyte solutions right up to the 2 hour mark.

Is the only way around this to get real good at bedside gastric ultrasound interpretation and make a determination obased solely on that?

I would much prefer we stick to our guidelines and ignore the Non-anesthetic recommendations. Analogous to Emergency Medicine guidelines saying it's safe to sedate nonfasted patients for procedures.

I think it’s only fair to question to ASA guidelines that have no evidence to support them .
 
And when it comes to a law suit, it will be hard to defend yourself when you did not follow your own “guidelines”?

Again they argue they are just “guidelines” not hard and fast rules

anyone more knowledgeable on the law side of this?
 
I think we should gastric ultrasound every patient on glp1 drugs preop and use that in the decision tree. But I don't think a lot of people know how.
They will start to know soon
It’s being tested on the osce this year
 
I think we should gastric ultrasound every patient on glp1 drugs preop and use that in the decision tree. But I don't think a lot of people know how.
Private practice Gi egd scopes are 2 minutes

If doc is preop 3-4 gi rooms 40’patient a day.
It will delay procedures with ultrasound assuming 5% of gi patients likely to be on it these days
 
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Private practice Gi egd scopes are 2 minutes

If doc is preop 3-4 gi rooms 40’patient a day.
It will delay procedures with ultrasound assuming 5% of gi patients likely to be on it these days


That’s a nightmare job.
 
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Private practice Gi egd scopes are 2 minutes

If doc is preop 3-4 gi rooms 40’patient a day.
It will delay procedures with ultrasound assuming 5% of gi patients likely to be on it these days

So all the more reason for the GI docs to make sure the patient held their glp1 drug. If they want anesthesia to sedate and they don't want to be delayed by gastric ultrasound
 
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That’s a nightmare job.
For lots of reasons beyond the torture of chart monkey work. You can't really be involved in the cases, so you've got CRNAs working them solo, high volume, in some of the higher risk patients and procedures in the hospital.

No thanks.
 
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Isn’t there some guidelines for colonoscopies they need to spend at min 6 mins looking?
Not sure about egd?
 



How are different places handling "macs" for patients on GLP-1 agonists?

American Gastroenterological Association says no data to support stopping these meds prior to endoscopic procedures.

Ortho is hopping on board and demanding patients don't stop the med and want spinals with heavy "macs". Also insist of patients drinking large volume electrolyte solutions right up to the 2 hour mark.

Is the only way around this to get real good at bedside gastric ultrasound interpretation and make a determination obased solely on that?

I would much prefer we stick to our guidelines and ignore the Non-anesthetic recommendations. Analogous to Emergency Medicine guidelines saying it's safe to sedate nonfasted patients for procedures.
I’m not sure you could show me two specialties sedation guidelines or preferences I care less about than GI or Ortho.

When your medical decision making is weighted towards speed/efficiency and it’s corollary (money) I don’t consider that a medical indication. The bias is high with them.
 
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Link from Today's email from the ASA:

 
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I think we should gastric ultrasound every patient on glp1 drugs preop and use that in the decision tree. But I don't think a lot of people know how.
Most patients on GLP1s I have seen are “fluffy” and gastric ultrasound can be unreliable and challenging in this population. I don’t really see the utility and I will continue to follow the ASA guidelines.

I have said this before but the gastroparesis induced by this drug class is unpredictable and I think stopping the med is prudent. What is the downside?
 
Link from Today's email from the ASA:



This has always been the practice on the west coast. Need to document medical necessity for anesthesia services or patients need to pay cash.
 
I think we should gastric ultrasound every patient on glp1 drugs preop and use that in the decision tree. But I don't think a lot of people know how.
I guess maybe this is the stage of my career when my toe is creeping over the threshold of apathy and dinosaurism.

Because I'm not sure I can muster the motivation to learn to do that, when the other alternative is to just tell the GI doc their office needs to get its **** together and properly counsel their patients on which meds to hold preop. It's not like our policy is a secret.

- pgg, budding Apathosaurus
 
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Most patients on GLP1s I have seen are “fluffy” and gastric ultrasound can be unreliable and challenging in this population. I don’t really see the utility and I will continue to follow the ASA guidelines.

I have said this before but the gastroparesis induced by this drug class is unpredictable and I think stopping the med is prudent. What is the downside?

I believe it is included in the current guidance if patient did not hold their glp1 drug and they are asymptomatic
 
I don’t think it is in any current guidelines. Can you please link what ASA guidelines say we should do a gastric ultrasound
I believe it said gastric ultrasound may be used in the decision making process.
 
Most patients on GLP1s I have seen are “fluffy” and gastric ultrasound can be unreliable and challenging in this population. I don’t really see the utility and I will continue to follow the ASA guidelines.

I have said this before but the gastroparesis induced by this drug class is unpredictable and I think stopping the med is prudent. What is the downside?
Should definitely stop the med, and give tine to let it wash out, no argument there.

Its not prohibitively difficult to image the stomach and liver in the moderately bigger (BMI 30-40s) patients. Yesterday, after first round cases were all underway, I saw my second cysto case (BMI mid-40s). She was booked only Monday, so she stopped her jardiance that day, as instructed (also on weekly monjaro, which was last given a week prior). It was not an urgent case, told the Urologist I may cancel, but she had no GI symptoms, so I figured I'd take the time to scan her. Stomach was easily imaged with the curvilinear probe on our block ultrasound, and seen decompressed in both supine and right lateral, so I printed an image for the chart, and says we could proceed.

Would I take the time to do this if behind or pressed for time, probably not. But, I trust my ability to perform the exam (regularly perform POCUS exams in the unit), and I had a few minutes to **** around and potentially save this lady a trip.
 
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I did gastric ultrasound for the first time a few weeks ago , it was relatively easy. Patient was obese. I could see the bullseye sign right away in supine and right lateral position. It was my first time so I still intubated the patient. Without the ultrasound , I would have cancelled case.

The problem is we don’t have the ultrasound machine in the Endo centers where the gi doctors are pretty aggressive.

Per ASA
If the patient has no GI symptoms, but the GLP-1 agonists were not held as advised, proceed with ‘full stomach’ precautions or consider evaluating gastric volume by ultrasound, if possible and if proficient with the technique. If the stomach is empty, proceed as usual. If the stomach is full or if gastric ultrasound inconclusive or not possible, consider delaying the procedure or treat the patient as ‘full stomach’ and manage accordingly. Discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
 
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The original article acknowledges that this is a retrospective chart review. The authors had no idea when these patients last took their GLP-1 agonist. For all they know, the patient could have been holding it per ASA guidelines. They only flagged patients with confirmed aspiration. If there was evidence of solid food in the stomach and either the GI doc had to abort or the anesthesia team had to alter their anesthetic and airway management, that is also clinically significant to me.
 
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people get away with so much crap...getting lucky becomes the norm, especially from the naïve point of view...looking in from the sidelines and then 'getting lucky' becomes the standard of care...what a mess...
 
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stopping the med or not is one thing (we should), whether to sedate with an unprotected airway is a second issue (I don’t, even if GLP-1 has been held)
 
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This has always been the practice on the west coast. Need to document medical necessity for anesthesia services or patients need to pay cash.
I have documented anxiety for this reason. I refused nurse sedation and requested an anesthesiologist with propofol.
 
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people get away with so much crap...getting lucky becomes the norm, especially from the naïve point of view...looking in from the sidelines and then 'getting lucky' becomes the standard of care...what a mess...
Agree so much. Plus humans don’t understand how to estimate risk
 
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Some of the older gi docs still insist on doing colonoscopy before egd. So annoying. They rather have patient aspirate than waste a good prep.
 
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Some of the older gi docs still insist on doing colonoscopy before egd. So annoying. They rather have patient aspirate than waste a good prep.
why?
Never heard of that and I used to do a lot of endo...
 
I read the study. It's at best a proof of concept that we need some further study, but I don't see any way you can look at their data and claim it's reassuring.

They have no information on if any of the patients in the study were actually talking their GLP-1 agonists (or if they had potentially held them), just that they had been prescribed them at some point in time. Now granted I'm willing to give them some benefit that most people probably weren't holding them prior until recently given that we didn't have guidelines to that end, but that's still a pretty remarkable hole.

Also I think this study is wildly underpowered given the rarity of the event. Some quick back-of-the-envelope math (aka using the first result under "statistical power calculator" on Google) suggests that to detect a 50% increase in an event with baseline incidence of 4.6/10,000 requires at least 70,000 patients... I'm not a stats whiz by any means but it's hard for me to imagine what you could find reassuring about a retrospective review of an order of magnitude fewer cases.

Now an interesting sidebar to all of this is that the rate of aspiration for patients receiving MAC is higher than those receiving proceduralist-directed nursing sedation -- again, it's all retrospective data but this has been borne out in several literature reviews. And that's even considering some fancy statistical tricks to try and risk-adjust the groups, though we all know those have their problems.


Gastric ultrasound is great but my problem is I'm not sure of the sensitivity, especially in the hands of an inexperienced operator (i.e., me). Obviously if we do see a full stomach on ultrasound that's helpful but not seeing a full stomach or getting a couple views where it looks empty... I'm less convinced.
 
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I have documented anxiety for this reason. I refused nurse sedation and requested an anesthesiologist with propofol.

You can always go with no sedation at all. That’s what another GI doc did earlier this week. Had a screening colonoscopy here at 7am and was back at his own center scoping patients before 8am.
 
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You can always go with no sedation at all. That’s what another GI doc down did earlier this week. Had a screening colonoscopy here at 7am and was back at his own center scoping patients before 8am.

Only works in a very small group of motivated patients. Not going to work for a 50 year old crybaby who drinks a bunch, takes benzos daily to help them sleep and has fibromyalgia.. unfortunately that can make up a significant portion of our patient population nowadays
 
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You can always go with no sedation at all. That’s what another GI doc down did earlier this week. Had a screening colonoscopy here at 7am and was back at his own center scoping patients before 8am.
My dad had that done once before his morning clinic. He said he didn't like it. I'd rather have the propofol and a day off work (I got to use a sick day with a university). But I did have to specifically request an anesthesiologist where RN sedation prevails for healthy people, so the GI doc said I had anxiety.
 
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Only works in a very small group of motivated patients. Not going to work for a 50 year old crybaby who drinks a bunch, takes benzos daily to help them sleep and has fibromyalgia.. unfortunately that can make up a significant portion of our patient population nowadays
I had 2 patients in the last few weeks who didn't want any sedation but the GI doc and Colorectal surgeon both refused to scope their patients without anesthesia. One of them had even had his previous scope done without anesthesia with another GI doc that recently left (30-something with well controlled Crohn's) and none of the current GIs were willing to do it without anesthesia for him.
 
I had 2 patients in the last few weeks who didn't want any sedation but the GI doc and Colorectal surgeon both refused to scope their patients without anesthesia. One of them had even had his previous scope done without anesthesia with another GI doc that recently left (30-something with well controlled Crohn's) and none of the current GIs were willing to do it without anesthesia for him.
I've had a few patients refuse anesthesia for EGDs and colos. Some come to the center without a ride. Most of them have had it done without anesthesia in the past. The GI docs have let them even though they always seem to be surprised when the patients refuse even if they have before.
 
My dad had that done once before his morning clinic. He said he didn't like it. I'd rather have the propofol and a day off work (I got to use a sick day with a university). But I did have to specifically request an anesthesiologist where RN sedation prevails for healthy people, so the GI doc said I had anxiety.

I would have anxiety too if they let a nurse push propofol on me
 
I had 2 patients in the last few weeks who didn't want any sedation but the GI doc and Colorectal surgeon both refused to scope their patients without anesthesia. One of them had even had his previous scope done without anesthesia with another GI doc that recently left (30-something with well controlled Crohn's) and none of the current GIs were willing to do it without anesthesia for him.

Recently had a young 30 year old patient who believes she has "mitochondrial disease", comes in with a large packet of paperwork listing every drug she refuses. Only thing she accepts is lidocaine.

Lido spray as a sole agent for an egd....amusing. I was not involved.
 
Recently had a young 30 year old patient who believes she has "mitochondrial disease", comes in with a large packet of paperwork listing every drug she refuses. Only thing she accepts is lidocaine.

Lido spray as a sole agent for an egd....amusing. I was not involved.

A bolus dose of propofol would have been just fine
 
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