American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1

[TheLoneWolf]

American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

www.asahq.org

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[Shimmy8]

Useless. But expected.

 

[DocVapor]

As expected. Not sure it's useless though as it's at least something we can take to surgeons and admin.

 

[TheLoneWolf]

I dunno how often I can get away with canceling EGDs in anticipation of bariatric surgery and moreso screening colonoscopies in general because they took their ozempic/wegovy within a week of scope and surgeons office never informed them to stop. Also never saw a GI suite with a readily available ultrasound to check for gastric contents.

It's already hard enough doing "mac" cases on >300lb patients on a near daily basis. This just adds another painful layer. Well now I can insist on GETA, I guess.

They should have titled this paper "GLP agonists- Get Suxxed!"

 

[DrOwnage]

It's already hard enough doing "mac" cases on >300lb patients on a near daily basis. This just adds another painful layer. Well now I can insist on GETA, I guess.

Its always during these colonoscopies you get the tech putting their entire body weight into the patients epigastric area in order for the scope to pass a loop. Great combination.

 

[Arch Guillotti]

I dunno how often I can get away with canceling EGDs and screening colonoscopies in anticipation of bariatric surgery because they took their ozempic/wegovy within a week of scope and surgeons office never informed them to stop. Also never saw a GI suite with a readily available ultrasound to check for gastric contents.

It's already hard enough doing "mac" cases on >300lb patients on a near daily basis. This just adds another painful layer. Well now I can insist on GETA, I guess.

They should have titled this paper "GLP agonists- Get Suxxed!"

Not sure if serious. Have you ever taken a colon prep? Yes, I get it they can still aspirate especially when 2 techs are standing on the protuberant belly.

And who does a screening colonoscopy prior to bariatric surgery? Never seen this before.

 

[TheLoneWolf]

Not sure if serious. Have you ever taken a colon prep? Yes, I get it they can still aspirate especially when 2 techs are standing on the protuberant belly.

And who does a screening colonoscopy prior to bariatric surgery? Never seen this before.

Should have clarified my wording, screening colonoscopies in general and EGDs for anticipated bariatric surgeries, two separate situations.

 

[sethco]

Not sure if serious. Have you ever taken a colon prep? Yes, I get it they can still aspirate especially when 2 techs are standing on the protuberant belly.

And who does a screening colonoscopy prior to bariatric surgery? Never seen this before.

How about patients undergoing TEEs?

 

[Hoya11]

American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

www.asahq.org

im surprised they are making an official stance without clear evidence and only anecdotal tales

 

[TheLoneWolf]

im surprised they are making an official stance without clear evidence and only anecdotal tales

My guess is a lot of disparate cases with some notable bad outcomes prompted a quick response.

 

[TheLoneWolf]

I recall a case of a weird young man ( suspected drug addicted laborer types with poor eye contact) coming in for an outpatient EGD for anemia, overuse of NSAIDs suspected. Npo past midnight and was one of the last cases of the day. As soon as they passed the scope in, whole stomach was filled with what appeared to be poorly chewed chunks of fruit salad. Like as in he probably ate it on his way in. Soooo mad. Surgeon said he wanted to proceed and biopsy and play around in there, I said nope let's get outta here. Luckily nothing untoward occurred.

Definitely don't want a repeat of that and don't want that to become our new routine practice with widespread use of these drugs.

 

[jwk]

Well now I can insist on GETA, I guess.

They should have titled this paper "GLP agonists- Get Suxxed!"

And there’s your answer. 😁

 

[Simba1711]

What are you guys doing with these new guidelines? Our group is discussing what to do . Some of the anesthesiologists just want to extend npo time rather than hold the medications as we are getting push back from the gi docs. This makes me uneasy but I’m the new guy at the shop so don’t really want to rock the boat. If it were up to me I would just follow the asa guidelines and hold the medications. Both of our Endo centers also don’t have ultrasound which I wouldn’t feel comfortable relying on anyway as I’m not used to doing gastric ultrasounds.

 

[Hoya11]

What are you guys doing with these new guidelines? Our group is discussing what to do . Some of the anesthesiologists just want to extend npo time rather than hold the medications as we are getting push back from the gi docs. This makes me uneasy but I’m the new guy at the shop so don’t really want to rock the boat. If it were up to me I would just follow the asa guidelines and hold the medications. Both of our Endo centers also don’t have ultrasound which I wouldn’t feel comfortable relying on anyway as I’m not used to doing gastric ultrasounds.

we are instructing patients to hold the medications, but not committing to cancelling the cases if they don't = anesthesiologist will decide to cancel or proceed on a case by case basis if meds not held per guidelines

i felt the ASA put us in a corner, without any data, making these guidelines that are hard to ignore and most likely useless..

 

[lane]

What are you guys doing with these new guidelines? Our group is discussing what to do . Some of the anesthesiologists just want to extend npo time rather than hold the medications as we are getting push back from the gi docs. This makes me uneasy but I’m the new guy at the shop so don’t really want to rock the boat. If it were up to me I would just follow the asa guidelines and hold the medications. Both of our Endo centers also don’t have ultrasound which I wouldn’t feel comfortable relying on anyway as I’m not used to doing gastric ultrasounds.

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[Simba1711]

Prop
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I wanted to specify for our outpatient gi centers.

 

[lane]

I wanted to specify for our outpatient gi centers.

Bring some dantrolene?

 

[Simba1711]

I’m in private practice so not really sure how feasible to treat every patient that doesn’t hold their medications as full stomach. A significant number of patients are on this right now for weight loss. I pretty much have to cancel the case since we don’t intubate per policy. If we do proceed with the case against the recommendations how defensible is it in court. I’m guessing it will look pretty bad if we go against our own society recommendations.

 

[lane]

I’m in private practice so not really sure how feasible to treat every patient that doesn’t hold their medications as full stomach. A significant number of patients are on this right now for weight loss. I pretty much have to cancel the case since we don’t intubate per policy. If we do proceed with the case against the recommendations how defensible is it in court. I’m guessing it will look pretty bad if we go against our own society recommendations.

We started noticing issues months ago when we had a couple colonoscopies vomit solid food products and saw significant gastric volumes on EGDs for patients who took ozempic. Granted we are in a hospital with a separate GI suite that has the capability to intubate any patient as needed. I would argue that you aren’t just following society recommendations or something arbitrary like running sevo at >2 L/min flows since there has been a widely observed risk for this patient population. I agree that it would look pretty bad if no additional precautions are taken given the new document.

 

[Arch Guillotti]

We have had a few egd’s with a stomach bloated with with food.

 

[The Duck Knows]

Anybody else concerned that just intubating will lead to surgeons/proceduralists expecting us to do the same for other NPO non adherence? I’m being understanding for now since it’s new for everyone, but it seems odd to “just intubate” a full stomach for an elective procedure

 

[lane]

Anybody else concerned that just intubating will lead to surgeons/proceduralists expecting us to do the same for other NPO non adherence? I’m being understanding for now since it’s new for everyone, but it seems odd to “just intubate” a full stomach for an elective procedure

We told them there’s a difference between waiting a couple hours vs waiting a week. But we have reasonable GI docs who appreciate limited shared liability

 

[The Duck Knows]

We told them there’s a difference between waiting a couple hours vs waiting a week. But we have reasonable GI docs who appreciate limited shared liability

What about other outpatient procedures? When they have hospital admission pre authorized? Or when they’re trying to get a surgery in at the end of the year?

I’m not being intentionally obtuse or argumentative. And I get that there’s a difference between the surgeons clinic dropping the ball and the patient eating a breakfast burrito on the way in. But this has typically been a slam dunk board scenario. It’s an optimizable condition to decrease risk of aspiration and death in an elective procedure.

Our group has made a list of meds and helped pre op offices give better instruction. Ultimately I think that will be the best solution.

 

[gcc322]

How often do you encounter patients that experience bloating/regurgitation? Our preop office has been flagging patients on the meds for the last few month so we are aware. I typically ask about any cramping/nausea/etc and I have only had 1 out of 20-30 positive. I discuss the risks with the patient and surgeon and move along with the case. I haven’t had a patient cancel so far and don’t expect that to change.

 

[lane]

What about other outpatient procedures? When they have hospital admission pre authorized? Or when they’re trying to get a surgery in at the end of the year?

I’m not being intentionally obtuse or argumentative. And I get that there’s a difference between the surgeons clinic dropping the ball and the patient eating a breakfast burrito on the way in. But this has typically been a slam dunk board scenario. It’s an optimizable condition to decrease risk of aspiration and death in an elective procedure.

Our group has made a list of meds and helped pre op offices give better instruction. Ultimately I think that will be the best solution.

We have been working with our pre-admission testing clinic to communicate with patients and surgeons the risks and preference to hold them for at least a week when possible. For those who don’t have sufficient time (or their endocrinologist is unable to bridge them) we RSI. It’s not perfect but we feel it shows we’re controlling what we’re reasonably able to control to mitigate risk as much as possible.

 

[painstop]

Looks like the gastroparesis issue is becoming part of the zeitgeist now so we cannot ignore it. Some anesthesiologists made comments at the end of the story:

https://www.cnn.com/2023/07/25/health/weight-loss-diabetes-drugs-gastroparesis/index.html

 

[coffeebythelake]

“Lung tissue is fragile and precious,” George said. “If anything goes into the lungs, at best, it’s a cough, at worse, you end up on a ventilator for an extended period of time,” she said.

Actually, at worst, the patient develops severe ARDS and dies.

 

[GassYous]

“Lung tissue is fragile and precious,” George said. “If anything goes into the lungs, at best, it’s a cough, at worse, you end up on a ventilator for an extended period of time,” she said.

Actually, at worst, the patient develops severe ARDS and dies.

Not always. Death may be preferable to rotting in a vent farm for month

 

[Airway]

“Lung tissue is fragile and precious,” George said. “If anything goes into the lungs, at best, it’s a cough, at worse, you end up on a ventilator for an extended period of time,” she said.

Actually, at worst, the patient develops severe ARDS and dies.

Regional anesthesiologist, probably lots of blocks and not a lot of ICU patients 😆

 

[IMGASMD]

I shared my conversation with my GI bros before, and this bro actually runs their own Endoscopy Center with them supervising the crna’s. So you take this for whatever it’s worth to you.

GI nurse: “hey, Dr. IMGASMD, this patient is on ozempic, what should they do with that for EGD….”

IMGASMD: “ummmm…. I am not sure what do we do as an department….”

Gastroenterologist who overhead the conversation: “dude that stuff makes patients have the worst gastroparesis, sometimes their stomach is completely full… you should tell them stop taking it before coming in….”

There you have it. I am not sure if he personally had an aspiration on HIS watch or what…. But if he isn’t welling to take that responsibility, why should we?

Just anecdotal stuff, but made me think a lot.

 

[POW16]

My department has implemented the guidance from ASA. It's still up to each doc but hard to defend a bad outcome if you don't follow the guidance.

 

[TheLoneWolf]

Popular weight-loss drugs like Wegovy may raise risk of complications under anesthesia

Patients taking blockbuster drugs like Wegovy for weight loss may face potentially deadly complications if they need surgery or other procedures that require empty stomachs for anesthesia.

apnews.com

Also seeing commercials for lawyers asking if you had complications from these new drugs to contact them. Let's see it play out. So far, my department has not made any changes or mention of these guidelines.

 

[coffeebythelake]

My department has implemented the guidance from ASA. It's still up to each doc but hard to defend a bad outcome if you don't follow the guidance.

We are even more conservative than guidance. We also have patients do extended NPO times.