Updated GLP-1 recommendations

[Scotty_G]

---

Members don't see this ad.

I wanted to get updates on amount of time to hold GLP-1's. Obviously there has been some back and forth over the last few years on this issue. Is consensus still 7 days on injectables?

 

[abolt18]

I think our policy right now is, hold 7 days or clear liquid diet for 24h before surgery.

 

[Guillemot]

I wanted to get updates on amount of time to hold GLP-1's. Obviously there has been some back and forth over the last few years on this issue. Is consensus still 7 days on injectables?

I believe the old guidance of 7 days hold that was recommended by the ASA a while back is no longer endorsed by the ASA or AFAIK analogous international societies. AFAIK that recommendation did not have a basis in evidence and also didn't really make sense from a pharmacokinetic standpoint. At this time the ASA has declined to offer clear guidance on the matter. For this reason many people and institutions still adhere to 7 days because they want to feel like they are doing something to protect patients.

 

[Scotty_G]

Yes I know the ASA has declined to offer new guidelines. I was curious if some of you were doing 24 hr clear liquid diet instead of holding 7 days. It takes many weeks for the gastric emptying to return to normal. I am building guidelines for a new center and trying to be reasonable since so many people are on them.

 

[MirrorTodd]

Personally, I'm just proceeding if they are taking it for weight loss, further eval if they have diabetes. Admittedly, I basically RSI all my patients nowadays anyway. Covid pretty much proved that you don't need to mask ventilate to confirm ventilation. Obviously, if the airway is screwy, then further eval is needed too.

 

[JoelJoel84]

Personally, I'm just proceeding if they are taking it for weight loss, further eval if they have diabetes. Admittedly, I basically RSI all my patients nowadays anyway. Covid pretty much proved that you don't need to mask ventilate to confirm ventilation. Obviously, if the airway is screwy, then further eval is needed too.

Do you RSI everyone with Sux, or with Roc?

Just curious

 

[PlayToWin]

Do you RSI everyone with Sux, or with Roc?

Just curious

Either or works. If it’s truly short case then sux makes sense otherwise you’ll be giving 400 + Sugammedex on those patients.


Some centers are requiring holding glp1 and clear liquid diet from noon the prior day. There’s a balance between safety and getting cases done. Hopefully more literature will come out to clarify guidelines.

 

[CopaceticOne]

Do you RSI everyone with Sux, or with Roc?

Just curious

Lots of propofol with a phenyl push chaser 😉

I jest, but sometimes enough propofol is good for single attempt intubation. Have done it numerous times for cases that need neuromonitoring. Of course the patient also gets opioid and a good dose of IV lidocaine pre induction.

 

[cchoukal]

Either or works. If it’s truly short case then sux makes sense otherwise you’ll be giving 400 + Sugammedex on those patients.


Some centers are requiring holding glp1 and clear liquid diet from noon the prior day. There’s a balance between safety and getting cases done. Hopefully more literature will come out to clarify guidelines.

and speaking of more data regarding NPO durations...

https://www.sciencedirect.com/science/article/abs/pii/S0039606025003356

 

[Guillemot]

and speaking of more data regarding NPO durations...

https://www.sciencedirect.com/science/article/abs/pii/S0039606025003356

I believe most of the ASA guidelines were based off gastric emptying/volume studies and pH determination(including things such as reglan, h2 blocker, ). Cant do a RCT fasting interval/aspiration as it would be unethical. Without reading the article, the generalizability and clinical relevance sounds questionable. Maybe Ill look at it later, but probably not.

 

[DrN2O]

Personally, I'm just proceeding if they are taking it for weight loss, further eval if they have diabetes. Admittedly, I basically RSI all my patients nowadays anyway. Covid pretty much proved that you don't need to mask ventilate to confirm ventilation. Obviously, if the airway is screwy, then further eval is needed too.

What did you need COVID to prove: no need to 1) mask oxygenate before intubation, or 2) mask ventilate before giving paralytics? #1 is still a good idea. #2 Masking before paralytic is just dogma to haze/teach CA0s. Obviously there is also the theoretical risk of anaphylaxis with higher suggamedex dose.

 

[Arch Guillotti]

Personally, I'm just proceeding if they are taking it for weight loss, further eval if they have diabetes. Admittedly, I basically RSI all my patients nowadays anyway. Covid pretty much proved that you don't need to mask ventilate to confirm ventilation. Obviously, if the airway is screwy, then further eval is needed too.

This dogma was disproved a while ago.

 

[MirrorTodd]

Do you RSI everyone with Sux, or with Roc?

Just curious

Roc mainly, but depending on the case and speed of the surgeon, I'll use sux.

 

[MirrorTodd]

This dogma was disproved a while ago.

I'm sure it was but still a big thing in residency through Covid at least.

 

[Arch Guillotti]

I'm sure it was but still a big thing in residency through Covid at least.

Because a lot of academic attendings are very dogmatic.

 

[Aether2000]

Is GLP-1 concern really a big yawn. Yes, they increase gastric emptying time T1/2 by 36 minutes. Is that clinically relevant? Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A Systematic Review and Meta-Analysis With Insights for Periprocedural Management - PubMed. But then there is this: Europe PMC There are also reports of full stomach even following the guidelines of the ASA preop use of GLP-1. There are even more reports of full stomachs or delayed gastric emptying in those not taking GLP-1s- patients with diabetes, obesity, achalasia, eosinophilic esophagitis, prior gastric surgery, peptic ulcer disease, viral or bacterial infections, heart transplants, labyrinthine disease, seizures, parkinsons, guillain-barre, MS, dysautonomias, anxiety, scleroderma, SLE, amyloidosis, CRF, hypokalemia, hypomagnesemia, hypocalcemia, and others, . Similarly, opioids, methamphetamine, cocaine, TCAs, anticholinergics, calcium channel blockers, antipsychotics, marijuana, H2 blockers, Zofran, proton pump inhibitors, sucralfate, aluminum hydroxide antacids, levodopa, lithium, alcohol, interferon, cyclosporine, benadryl, metformin, sulfonylureas, phentermine, progesterone, and many others cause delays in gastric emptying. In many cases, patients may forget they have some of these conditions or forgot about taking certain medications or conceal use of medications. The only way to be sure is to do a gastic POC ultrasound.

 

[triggermaster]

What about euglycemic ketoacidosis? (Mounjaro)

 

[Aether2000]

What about euglycemic ketoacidosis? (Mounjaro)

While there have been a few case reports, it is rare, and can occur within a few weeks of starting the medication with or without surgery/anesthesia.

 

[Guillemot]

Is GLP-1 concern really a big yawn. Yes, they increase gastric emptying time T1/2 by 36 minutes. Is that clinically relevant? Quantified Metrics of Gastric Emptying Delay by Glucagon-Like Peptide-1 Agonists: A Systematic Review and Meta-Analysis With Insights for Periprocedural Management - PubMed. But then there is this: Europe PMC There are also reports of full stomach even following the guidelines of the ASA preop use of GLP-1. There are even more reports of full stomachs or delayed gastric emptying in those not taking GLP-1s- patients with diabetes, obesity, achalasia, eosinophilic esophagitis, prior gastric surgery, peptic ulcer disease, viral or bacterial infections, heart transplants, labyrinthine disease, seizures, parkinsons, guillain-barre, MS, dysautonomias, anxiety, scleroderma, SLE, amyloidosis, CRF, hypokalemia, hypomagnesemia, hypocalcemia, and others, . Similarly, opioids, methamphetamine, cocaine, TCAs, anticholinergics, calcium channel blockers, antipsychotics, marijuana, H2 blockers, Zofran, proton pump inhibitors, sucralfate, aluminum hydroxide antacids, levodopa, lithium, alcohol, interferon, cyclosporine, benadryl, metformin, sulfonylureas, phentermine, progesterone, and many others cause delays in gastric emptying. In many cases, patients may forget they have some of these conditions or forgot about taking certain medications or conceal use of medications. The only way to be sure is to do a gastic POC ultrasound.

I actually made a thread about gastric POCUS recently: The Dilemma of Gastric POCUS

Most of the participants felt that they were either too stupid and/or lazy to learn how to perform the exam.

Additionally, although you can see that an individual has a full stomach on gastric POCUS, you’d ideally be doing something to optimize the patient before hand so they don’t show up on the day of surgery in a state of elevated risk.

 

[Guillemot]

I found this article to be informative: Perioperative Management of Patients Taking Glucagon-like... : Anesthesiology

At the end of the article they propose a pathway for GLP-1 based on a mix of expert opinion and evidence that IMO seems practical and not too complicated. It includes gastric POCUS and an extended interval of fasting.

 

[A Deep Breath]

This dogma was disproved a while ago.

Do you forgo mask ventilation in all cases? If not, when do you do it?