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

[Ashers]

I would have anxiety too if they let a nurse push propofol on me

The nurse sedation was versed, fentanyl, benadryl for GI. I wanted a fast recovery with propofol and an anesthesiologist not a CRNA.

GI docs were pushing to get them to use ketamine and propofol for scopes, but I was in charge of sedation at my hospital, and the nurses refused. The ER is a different story.

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[coffeebythelake]

The nurse sedation was versed, fentanyl, benadryl for GI. I wanted a fast recovery with propofol and an anesthesiologist not a CRNA.

GI docs were pushing to get them to use ketamine and propofol for scopes, but I was in charge of sedation at my hospital, and the nurses refused. The ER is a different story.

ER is crazy world.

 

[Gastrapathy]

I think it’s very clear GLP-1s cause gastroparesis. Skipping a single dose, however, is a pointless recommendation. It’s a knee jerk that isn’t based on any evidence. Opioids cause gastroparesis but aren’t new. Tirzepatide, for example, has a 5 day half life and symptoms/side effects are common at 2.5mg q week so it’s safe to assume gastric emptying is affected. The weight loss dose is 10-15mg q week.

So for GLP-1s, regardless of whether they have held the drug, they are still gastroparetic. Making them wash it out enough to recover normal gastric function would take weeks and just isn’t realistic.

My approach to any patient in whom I suspect gastroparesis (so also for known diabetic gastroparesis patients for example) is to do clears for a day prior and then NPO for 6 hours prior to the procedure. This does change their bowel prep instructions to our gastroparesis version. We comply with the anesthesiology requirements for propofol cases but I don’t understand them.

 

[Gastrapathy]

Also: we do unsedated colons all the time. Uppers less frequently as that is pretty tough. There are selected patients I would refuse to do unsedated but most of the people who want it can handle it.

 

[DocMcCoy]

Also: we do unsedated colons all the time. Uppers less frequently as that is pretty tough. There are selected patients I would refuse to do unsedated but most of the people who want it can handle it.

Is this a regional thing? US? Just curious. It’s exceedingly rare to see unsedated GI procedures around me. Very rarely seen flex sigs like 2 in six years and those are the only instances of truly unsedated GI procedures I’ve heard of at our institution. I know it can be done just wondering where this is happening all the time. How do you select for it? What do you do if the patient isn’t tolerating? I’m imaging a time consuming procedure with little insulation and gentle maneuvering and a lot of patience.

Our GIs are awesome but they don’t necessarily have a gentle touch. Lowest I’ve gone is 2mg of versed in a stoic guy that didn’t want to be “out all the way”. There were points where he was pretty damn uncomfortable.

 

[Gastrapathy]

@DocMcCoy patients request it fairly frequently and it really isn’t a big deal. Id guess I do 2 a month. Warm water insufflation instead of CO2 and maybe an extra minute to the cecum. Not great in thin women or patients with bad diverticular disease but most people tolerate it fine. I’ve only had a couple I’ve regretted. Often it’s doctors, lawyers, etc. I also offer it to the super obese patients who would be OR cases for any sedation because I try to never go behind enemy lines

 

[Ronin786]

I've said this in other threads, but gastric ultrasound isn't the answer. Are you really going to RSI every patient showing up for EGD with an intermediate result? We need better data as far as transit time in patients on these meds and then adjust their NPO time or do clears only for 24 hours prior.

 

[Agast]

What do you do for patients with history of gastroparesis on their charts? Separate from the issue of being GLP meds, I mean. Are they canceled if they didn’t do clears only the day before surgery?

 

[Hoya11]

Is this a regional thing? US? Just curious. It’s exceedingly rare to see unsedated GI procedures around me. Very rarely seen flex sigs like 2 in six years and those are the only instances of truly unsedated GI procedures I’ve heard of at our institution. I know it can be done just wondering where this is happening all the time. How do you select for it? What do you do if the patient isn’t tolerating? I’m imaging a time consuming procedure with little insulation and gentle maneuvering and a lot of patience.

Our GIs are awesome but they don’t necessarily have a gentle touch. Lowest I’ve gone is 2mg of versed in a stoic guy that didn’t want to be “out all the way”. There were points where he was pretty damn uncomfortable.

yeah these people are nuts

 

[Robotic Wis-Hipple]

What do you do for patients with history of gastroparesis on their charts? Separate from the issue of being GLP meds, I mean. Are they canceled if they didn’t do clears only the day before surgery?

You RSI them. But this isn’t the same. In one they have a condition that isn’t voluntary or modifiable while in the other they are taking a med (often for weight loss) that can be stopped for elective procedures.

 

[Gaseous Clay]

Sorry if this has been discussed elsewhere, but are people billing for a gastric ultrasound? If so any details with coding would be appreciated.

 

[Ronin786]

You RSI them. But this isn’t the same. In one they have a condition that isn’t voluntary or modifiable while in the other they are taking a med (often for weight loss) that can be stopped for elective procedures.

Except the half life of GLP meds is so long that you really can't feasibly stop it.