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?

 

[Arch Guillotti]

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

“Test” ventilation is almost never helpful.

 

[nimbus]

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

99% for me. I’ll mask for nasal intubations when I’m trialing a nasal trumpet through the nares.

 

[GassYous]

99% for me. I’ll mask for nasal intubations when I’m trialing a nasal trumpet through the nares.

You don't need to do that
Just warm the 7.0 tube in water and slide it in after some afrin and lube

 

[nimbus]

You don't need to do that
Just warm the 7.0 tube in water and slide it in after some afrin and lube

Old habit. I find 7.0 nasal RAEs too short for a lot of men so I try to use 8.0s.

 

[Aether2000]

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.

Really, for those that already are doing ultrasound guided injections, a gastric ultrasound takes about 3 minutes. 1-8 MHz range curved transducer, find the liver edge, scan over the aorta then the horizontal superior mesenteric artery leading to the image of the gastric fundus. Content ID and cross-sectional area can be estimated. Moreover, if a patient is lying to you about being NPO, it is easy to catch on US.

 

[Arch Guillotti]

Old habit. I find 7.0 nasal RAEs too short for a lot of men so I try to use 8.0s.

Just use an MLT tube.

 

[abolt18]

Really, for those that already are doing ultrasound guided injections, a gastric ultrasound takes about 3 minutes. 1-8 MHz range curved transducer, find the liver edge, scan over the aorta then the horizontal superior mesenteric artery leading to the image of the gastric fundus. Content ID and cross-sectional area can be estimated. Moreover, if a patient is lying to you about being NPO, it is easy to catch on US.

It'll take half my patients more than 3 minutes just to turn on their right side for the ultrasound.

 

[circleK]

In residency I remember a grand rounds debate between two attendings: mask ventilate vs don’t mask ventilate before paralytics. **** got heated!
Only in academia…

 

[Maverikk]

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.

I do this as well for my neuromonitoring cases, I like these cases bc I like remi but rarely use it because I try to be cost conscious. Good pre oxygenation with a decent seal and telling the patient to focus on their breathing if the good-intentioned circulator is trying to chit chat to relax them helps. Had a very good attending who made all the CA1s pre oxygenate to an end tidal O2 and then wait till they started to desaturate to intubate. It was interesting, young healthy people would go for what seemed like forever as everyone was watching. Then he would have us do it in just a moderately obese patient to see the difference.

In residency I remember a grand rounds debate between two attendings: mask ventilate vs don’t mask ventilate before paralytics. **** got heated!
Only in academia…

Our program director set up debates like this and gave two teams of residents a pro/con side to defend. One of the most interesting and clinically useful things to question ‘why am I doing this’ or ‘is there a better way’

In that spirit: I approach the glp1 recommendations as a reason to evaluate each case individually: are they having gastric symptoms, I do think gastric ultrasound is useful and I’ve had to teach myself, and what’s the aspiration risk to the patient. It’s like the sglt2 inhibitor recommendations, I had a cataract cancel bc of that, that patient had made arrangements for surgery, probably got charged a facility fee. Despite mine and the ophthalmologist protests it was ‘policy,’ I didn’t fight it hard bc I hadn’t been there long. Policies/guidelines/recommendations are to help guide a human experienced brain with wisdom from experience. I canceled an outpatient 5 min egd for a patient with new onset afib, wasn’t a hot disaster coming in but didn’t feel right: non-compliant, needed a bath/dental work, couldn’t get any relevant history despite going full interrogation/redirection mode. GI guy I got along with annoyed then the next week he told me he was hospitalized with a MI a week later, one of those cases I felt soft about canceling but now won’t forget