Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast is an exciting journey towards improved anesthesia patient safety.
We are returning to the conversation about GLP-1 receptor agonist medications today and listening to episodes #160 and #161 again. Patients taking these medications may be at increased risk for aspiration even after an appropriate preoperative fasting period. Tune in today as we talk about how to keep patients taking GLP-1 receptor agonists safe during anesthesia care.
Additional sound effects from: Zapsplat.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/189-glp-1-receptor-agonist-recommendations-revisited/
© 2024, The Anesthesia Patient Safety Foundation
Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast is an exciting journey towards improved anesthesia patient safety.
We are returning to the conversation about GLP-1 receptor agonist medications today and listening to episodes #160 and #161 again. Patients taking these medications may be at increased risk for aspiration even after an appropriate preoperative fasting period. Tune in today as we talk about how to keep patients taking GLP-1 receptor agonists safe during anesthesia care.
Additional sound effects from: Zapsplat.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/189-glp-1-receptor-agonist-recommendations-revisited/
© 2024, The Anesthesia Patient Safety Foundation
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are returning to a very important topic. Anesthesia professionals continue to have concerns related to patients taking Semaglutide and other GLP-1 Agonists medications and the risk for aspiration. These are newer medications, and this has led to a new threat to anesthesia patient safety.
Before we dive into the episode today, we'd like to recognize Preferred Physicians Medical Risk Retention Group, a major corporate supporter of APSF. Preferred Physicians Medical Risk Retention Group has generously provided unrestricted support to further our vision that "no one shall be harmed by anesthesia care". Thank you, Preferred Physicians Medical Risk Retention Group - we wouldn't be able to do all that we do without you!"
Our featured article today is “Are Serious Anesthesia Risks of Semaglutide and Other GLP-1 Agonists Under-Recognized? Case Reports of Retained Solid Gastric Contents in Patients Undergoing Anesthesia” by William Beam and Lindsay Guevara. You can find this article in the October 2023 APSF Newsletter, so head over to APSF.org and click on the Newsletter heading. Fourth one down is Newsletter archives. Then, scroll down until you get to October 2023 and our featured article today. I will include a link in the show notes as well.
And now it’s time to return to Episode #160! Let’s take a listen.
[Episode #160] Before we get into the article, we are going to hear form William Beam, one of the authors. I will let him introduce himself now.
[Beam] “My name is William Brian Beam, and I'm an anesthesiologist and critical care consultant at Mayo Clinic in Rochester, Minnesota.”
[Bechtel] To kick off the show today, I asked Beam why he is so passionate about this topic. Let’s take a listen to what he had to say.
[Beam] “Ultimately, my passion is for patient safety. In 2018, I helped lead a quality initiative at our institution focused on aspiration events in our practice. And since that time have continued to work on championing efforts to bring awareness to the topic.
Aspiration is one of the leading causes of morbidity and mortality in patients undergoing anesthesia. As anesthesiologist, assessment of our patient's risk for aspiration is integral to planning a safe anesthetic. Recognizing high-risk patients and planning accordingly is key. The use of GLP-1 agonist seems to be growing exponentially, and I would venture many of us are caring for patients on these medications on a daily basis.
This class of medications has broad benefits for patients, but as we outline in our article, the effects on gastric motility may increase the risk of aspiration in some, even when standard NPO guidelines are followed. I am glad to have the opportunity to raise awareness of this topic and explore the optimal approach to risk mitigation.”
[Bechtel] Thank you so much to Beam for contributing to the show today, sharing his expertise on aspiration events, and being a champion of anesthesia patient safety.
Now, it’s time to get into the article. The authors open with a summary that highlights why glucagon-like peptide, or GLP-1 receptor agonists, are a threat to anesthesia patient safety. This class of medications is used for the treatment of type II diabetes. Recently, GLP-1 agonists were approved for weight loss for patients with obesity and the use of these medications has increased significantly. These medications are involved in direct gastric stimulation of GLP-1 receptors leading to delayed gastric emptying and the potential for retained gastric contents in patients presenting for anesthesia despite following standard fasting guidelines. Let’s take a look at a couple of cases of patients taking GLP-1 receptor agonists who were found to have high volumes of complex gastric contents after following the American Society of Anesthesiologists practice guidelines for preoperative fasting.
The first case involves a 60-year-old patient who presented for an MRI. The patient required sedation for the imaging due to claustrophobia. Other medical history included hypertension and overweight with a BMI of 28. The month prior, the patient started semaglutide which you may know by the name, Ozempic, for weight loss. The last dose was administered 7 days prior to presentation. Despite fasting from solid food for more than 18 hours, the patient described feeling “full” during the preoperative evaluation. A point-of-care gastric ultrasound was performed, which revealed solid gastric contents. The decision was made to cancel the sedation and imaging for fear of high risk of aspiration during the delivery of anesthesia.
The second case involves a 50-year-old patient with past medical history of obesity with a BMI 37, type 2 diabetes, hypertension, and obstructive sleep apnea who was scheduled to undergo a robotic-assisted hysterectomy for endometrial hyperplasia. She previously had gastroesophageal reflux disease, but these symptoms had resolved since she started tirzepatide, which has the brand name of Mounjaro. The last dose was administered 2 days before surgery. Other medications included: metformin, hydrochlorothiazide, pregabalin, oxycodone 5 mg PRN (intermittent use with last dose the day prior to surgery) and sertraline. She had been fasting since the night before surgery.
Anesthesia proceeded with an uneventful induction of general anesthesia and intubation. After intubation an orogastric tube was placed and gastric contents were suctioned. Check out Figure 1 in the article for what was suctioned by the gastric tube at this time. The case was uncomplicated from a surgical perspective. After the surgery was completed, the patient was transferred to the transport bed and sat up in preparation for emergence. Just before the patient was ready for extubation, she developed large volume emesis of particulate matter that was consistent with what she reported eating several days prior to surgery. You can check out Figure 2 in the article to see the contents of the suction canister. The good news is that the endotracheal tube remained in place at this time and the patient’s airway was protected. After the emesis was cleared, the patient was extubated without further events. She was closely observed in the PACU and did not have evidence to suggest gastro-pulmonary aspiration and was therefore, discharged home later that day.
Have you taken care of a patient being treated with a GLP-1 receptor agonist medication recently? Are you seeing more patients on these medications? Have you witnessed any similar cases? Let’s continue in the article to learn more.
So, why are we seeing more patients being prescribed GLP-1 receptor agonists now? These medications have been considered a “breakthrough” for the treatment of weight loss. GLP-1 receptors are expressed in the gastrointestinal tract, pancreas, heart, liver, and brain and stimulation of these receptors leads to weight loss, improved glycemic control in diabetic patients, and improved cardiac and renal outcomes. The primary mechanism of action is likely due to activation of vagal afferent nerves that innervate the stomach and direct binding to GLP-1 receptor on gastric mucosal cells leading to delayed gastric emptying. For diabetes treatment, there is the dual benefits of weight loss and stimulation of insulin secretion from pancreatic beta cells leading to improved hemoglobin A1c. The decrease in major acute cardiac events is likely related to overall risk factor reduction with decreased glycated hemoglobin level, improved blood pressure control, decreased body mass index, decreased low density lipoprotein cholesterol level, improved glomerular filtration rate, and decreased albumin to creatinine ratio. There may also be some direct stimulation of GLP-1 receptors on the myocardium leading to improved endothelial function and microvascular perfusion.
Side effects from these medications include nausea, vomiting, or diarrhea, but these symptoms may decrease over time with continued use. Other adverse effects may include acute pancreatitis and gallbladder and biliary disease including cholecystitis. Rare reactions may include anaphylaxis and angioedema.
This class of medications has important benefits for patients with obesity and diabetes, but keep in mind that there may be serious anesthetic risks as well. We know that GLP-1 receptor agonists act to delay gastric emptying. This may then lead to high volumes of complex gastric contents even after fasting for the appropriate time according to the ASA guidelines. That was certainly the case for the two patients that we discussed earlier who were taking GLP-1 receptor agonists to treat diabetes and help with weight loss. There is a real risk to patient for aspiration and this may be a devastating complication. Did you know that it is in the top three adverse events related to airway management in the ASA closed claims project?! Aspiration is most often due to passive or active regurgitation of gastric contents. It is imperative that we are able to recognize patient who have an increased risk for increased gastric volume in order to deliver a safe anesthetic and keep patients safe from aspiration.
Now, it’s time for a medication review. So, grab your notebooks and pencils. Check out Table 1 in the article which contains a list of common GLP-1 Receptor agonists. All of these medications undergo renal elimination.
· First up is Exanetide which is administered as a subcutaneous injection either twice daily for immediate release or weekly for extended release and has a half-life of 3 hours. This medication is associated with immune-mediated thrombocytopenia.
· Next is Lixisenatide which is no longer available in the United States. This medication is administered as a subcutaneous injection daily and has a half-life of three hours.
· Semaglutide is next which you may know by the brand names of Ozempic or Wegovy. The SubQ formulation is approved for weight loss and is administered weekly. There is also an oral formulation administered daily that is used for diabetes management. The half-life is the longest in this class of medications at 7 days.
· Another medication that has been approved for weight loss is Liraglutide which is administered as a daily subcutaneous injection and has a half-life of 12.5 hours.
· Dulaglutide, with the brand name Trulicity, is administered as a subcutaneous injection weekly and has a half-life of 4.5 days.
· Last on the list is a combination medication that is a GLP-1 and GIP, or glucose-dependent insulinotropic polypeptide receptor, agonist that has also been approved for weight loss and is administered as a weekly subcutaneous injection. The half-life is also quite long at 5 days.
Be on the lookout for these medications during your preoperative evaluation.
We have talked about how patients taking GLP-1 receptor agonists are at increased risk for delayed gastric emptying and having complex gastric contents when they present for anesthesia and surgery which places these patients at increased risk for aspiration. Before we wrap up for today, we are going to review Table 2 from the article: Risk factors for Aspiration.
Here are the risk factors for aspiration.
· Esophageal Pathology which includes achalasia, previous esophagectomy, and tracheal esophageal fistula.
· High risk for ileus or bowel dysmotility including acute pancreatitis, recent intra-abdominal surgery, inpatients receiving opioids, and patients with prolonged bed rest.
· Intra-abdominal Obstruction from either gastric outlet, small bowel, or colonic.
· Emergency cases
· Cases with prolonged duration or complexity
· Pregnancy
· Active GI Bleed
· And finally, Known, suspected or induced gastroparesis and this includes longstanding diabetes, neuromuscular disorders, and medications including the topic for our podcast today, GLP-1 agonists.
[Bechtel] And now, we are going to continue the conversation by revisiting Episode #161.
[Episode #161] At the time of this APSF article, the Society of Perioperative Assessment and Quality Improvement consensus recommendation is to hold GLP-1 receptor agonists o the day of surgery. The optimal time period for withholding these medications has not been defined yet. Remember, many of these medications have a long half-life and withholding the medication for at least 5 half-lives prior to surgery and anesthesia in order to resume normal gastric function may not be feasible. Medications in this drug class also have important cardiovascular benefits and minimal risk for hypoglycemia so continued administration during the perioperative period is another consideration.
There is a call to action to take a closer look at the current fasting guidelines for patients taking GLP-1 agonists. This may be an appropriate time to perform a gastric ultrasound in order to evaluate for the presence of gastric contents prior to proceeding with surgery and anesthesia. If ultrasound is not available, it is important to consider the brand-new ASA guidance on preoperative management for patients taking these medications. You may need to weigh the risks for increased gastric contents and take necessary steps to decrease the risk for aspiration by performing a rapid sequence induction with gastric decompression prior to emergence. You must remain vigilant since patients with residual solid gastric contents are at risk for emesis and aspiration during emergence.
In early June at the Mayo Clinic, the practice for perioperative management for patients taking GLP-1 receptor agonists included the following:
· Patients are instructed to hold GLP-1 agonists on the morning of surgery.
· Procedures should not be delayed or cancelled if taking the day of surgery.
· Be aware of increased risk for full stomach when planning anesthetic management.
· No evidence-based practice recommendations regarding changes in management during moderate, deep sedation, and monitored anesthetic care.
Anesthesia professionals are likely to provide anesthesia care for patients taking GLP-1 receptor agonists given the increased use and expanded approval for weight loss. It is important to consider the potential for delayed gastric emptying and increased risk for aspiration. Going forward, more studies are needed to evaluate the safety of these medications throughout the perioperative period.
We aim to bring you the latest in perioperative patient safety, so we need to turn our attention to the June 29, 2023, publication of the “American Society of Anesthesiologists Consensus-Based Guidance on Preoperative Management of Patients (Adults and Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists” by Joshi and colleagues. I will include a link in the show notes as well.
The guidance includes a description of the FDA approval of GLP-1 receptor agonists for the treatment of type 2 diabetes and cardiovascular risk reduction and for weight low. Side effects of these medications may include adverse gastrointestinal effects such as nausea, vomiting, and delayed gastric emptying which is likely related to rapid tachyphylaxis of vagal nerve activation. Keep in mind that the effects on gastric emptying may be reduced with long-term use. Given these side effects, anesthesia professionals are appropriately concerned about the increased risk for regurgitation and aspiration of gastric contents during anesthesia care. Symptomatic patients with nausea, vomiting, dyspepsia and abdominal distention while taking GLP-1 agonists are at increased risk for retained gastric contents. Pediatric patients between the ages of 10-18 years old may be taking these medications for type 2 diabetes and weight loss with similar adverse gastrointestinal events to adults. At this time there is limited evidence for this guidance with several case reports, but given the serious complications of regurgitation and aspiration, the ASA task force has made the following suggestions for elective procedures. Don’t forget that for patients undergoing urgent or emergent procedures, do not delay going to the operating room with full stomach precautions and appropriate management.
Here are the ASA considerations for patients undergoing elective procedures:
In the Day(s) Prior to the Procedure:
· For patients on daily dosing consider holding GLP-1 agonists on the day of the procedure/surgery. For patients on weekly dosing consider holding GLP-1 agonists a week prior to the procedure/surgery.
· This suggestion is irrespective of the indication (type 2 diabetes mellitus or weight loss), dose, or the type of procedure/surgery.
· If GLP-1 agonists prescribed for diabetes management are held for longer than the dosing schedule, consider consulting an endocrinologist for bridging the antidiabetic therapy to avoid hyperglycemia.
On the Day of the Procedure:
· If gastrointestinal (GI) symptoms such as severe nausea/vomiting/retching, abdominal bloating, or abdominal pain are present, consider delaying elective procedure, and discuss the concerns of potential risk of regurgitation and pulmonary aspiration of gastric contents with the proceduralist/surgeon and the patient.
· If the patient has no GI symptoms, and the GLP-1 agonists have been held as advised, proceed as usual.
· 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.
· There is no evidence to suggest the optimal duration of fasting for patients on GLP-1 agonists. Therefore, until we have adequate evidence, we suggest following the current ASA fasting guidelines.15,16.
What is the policy at your institution? Are you following the new ASA consensus-based guidance? We hope that these considerations help you to be able to continue to provide safe anesthesia care and decrease the risk for aspiration.
Before we wrap up for today, we are going to hear from Beam again. He is going to share what he hopes to see going forward. Let’s take a listen.
[Beam] “The optimal approach to the perioperative management of patients on GLP one agonists has yet to be defined, and I suspect will continue to be a hot topic, although it may be appealing to recommend holding these medications prior to anesthesia.
The prolonged half-life of many of these medications makes this potentially impractical. Alternative recommendations to the NPO rules might be considered, for instance, at our institution in patients at high risk for residual gastric contents such as those with known gastroparesis or acsa, we routinely recommend a clear liquid diet for 48 hours prior to anesthesia.
This or other alterations to the fasting guidelines could be considered in this population as well. Finally, the routine use of gastric ultrasound may be very beneficial to help with decision making with some practice. The contents of the stomach of patients with normal gastric anatomy can determined at the bedside in just a few minutes.
In the near future, the three Mayo Clinic sites will be starting a prospective observational study using gastric ultrasound to determine the risk of retained gastric contents in patients on GLP one agonists undergoing anesthesia.”
[Bechtel] Thank you so much to Beam for contributing to the show today. We are looking forward to hearing more about the gastric ultrasound for patients on GLP-1 agonists study in the future. Are you performing a gastric ultrasound in the preoperative holding area to evaluate for retained gastric contents? Aspiration remains a big threat to anesthesia patient safety, and it is important to remain vigilant especially for patients who are at high risk for retained gastric contents.
[New to Record] Thanks for joining us for a review of this very important anestheisa patient safety topic. If you have any questions or comments from today’s show, please email us at podcast@apsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.
While waiting for the next show to drop, if you have not done so already, we hope that you will rate us and leave a review on iTunes or wherever you get your podcasts. Plus, we hope that you share this podcast with your friends and colleagues and anyone that you know who is interested in anesthesia patient safety. Are you an attending or senior consultant anesthetist or anesthesia professional with a roll in education? Don’t forget to share this resource with any anesthesia trainees or others on the perioperative team to help improve anesthesia patient safety going forward.
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2024, The Anesthesia Patient Safety Foundation