March FY21

[kristenhorsman]

The March journal club is presented by Kelsie St. Hill. She chose an AANA article entitled "Type 2 Diabetes Mellitus: Relationships Between Preoperative Physiologic Stress, Gastric Content Volume and Quality, and Risk of Pulmonary Aspiration.

You can find the article here.

Please respond to the following two questions:

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?

2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?

[Dahlia Rouchon]

1. In my practice I have never performed gastric US.
2. I think gastric US may prove useful but do not think it will change my practice. If it was found a large amount of gastric fluid was present, I may employ RSI for induction. What would modify my plan would be high HbA1c readings. I may elect to do GETA over LMA or not IVSD in these instances, especially if the patient has obesity. A great article. Thank you!

[nanci]

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?
I have not performed gastric ultrasonography.

2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?
I think that there are definite uses for preoperative gastric ultrasonography. For instance, with out Endoscopy suite this information would be utilized a lot especially for EGDs and patients that sedation might be questionable d/t unknown status of degree of gastroparesis. With the ERAS protocols and drinking up to 2 hours prior to a surgical procedure it would also be nice to see (and trend) gastric contents. Knowing those amounts may make a difference in how one approaches the anesthetic. Going into a situation with more factual assessment and information may bring safer outcomes overall. There is a lot of room for studies with this going forward.

[Lu Lin]

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?

In my practice, I have not performed gastric Ultrasonography.

2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?

It is a great article. Thank you for sharing! I think gastric ultrasonography is helpful in pre-op. I will probably not change my practice. For any patient if I think they have increase risk for aspiration, Morbid obesity, uncontrolled DM, etc, I will use RSI and intubate pt.

[Amy Swank]

1. I have not yet performed gastric ultrasonography.

2. I do not think performing gastric ultrasonography is a reasonable, viable procedure to do on a large number of patients - for instance, all adult Type 2 diabetics presenting for elective surgeries as in this journal article. Another pre-op procedure to do that would, potentially, delay the start of the case and most likely not add benefit to the pre-operative work-up would be my reason for this opinion.
There is some food for thought (pardon the pun) for perhaps using this procedure with the right patient, right procedure to help decrease any possible risk... for instance - an insulin dependent or high risk NIDDM, diabetic who presents for an IV sedation case - maybe a colonoscopy where the likelihood of abdominal pressure might lead to emesis and possible aspiration with a gastroparetic patient?

thanks for the interesting read.

[Anne McNulty CRNA]

1. I have never performed gastric ultrasonography . 2. I think this is potentially useful in preventing aspiration. I do not think it would be that time consuming that it would delay a case. I prefer rapid sequence induction for high risk patients. If you have never had a patient aspirate, you have not done many cases. The risk is always existing. This would be useful in the endo suite. A bladder scan can be done in pre-op and pacu to evaluate urinary retention. I have no idea of what this ultrasound machine costs but it has to be less than a week of in patient ventilation.

[Soo-Ok Kim]

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?
I have not performed gastric ultrasonography in my practice.

2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?
Although gastric ultrasonography may be useful, there are several limitations I consider troubling.
Time constraints, equipment availability, and the provider's competency with ultrasonography (technique and reading of the finding) can be challenging when there is little benefit to the test compared to the standard approach to gastric emptying issue. I would approach to T2DM pt with poor glucose control evidenced by high HgbA1C with RSI/GETA like others mentioned.

I am surprised by the statistic indicating in this article,
"One of the more serious complications
is pulmonary aspiration, which accounts for
10% to 30% of anesthesia-related deaths.1,2"

10-30% seems to be extremely high when only considering pulmonary aspiration.

[Wai-Ling Lo]

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?
No I haven't done gastric ultrasound before.

2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?
WIth obesity and diabetes epidemic, prevalence of hidden gastroparesis may be more significant than one expects. A preop point of care gastric ultrasound will be helpful to screen this group of pts so that we can plan the anesthesia care accordingly (like others have mentioned, sedation vs GETA). Like Ann said, if we do bladder scan to check residual urine to determine appropriate treatment, why not gastric US. Of course, more research will be needed to determine the cost benefit analysis. BTW, there are multiple research articles finding stating that point of care gastric US is simple, accurate and rapid tool to assess individual pt's gastric content.

[Jennifer Hannon]

1. In my practice I have never performed gastric US.
2. I think gastric US may change my practice if it was found a large amount of volume was present, I would switch to a RSI for induction. Good read, thank you for the article.

[aileenm4]

1. I have never performed gastric US
2. It would be helpful for certain high risk patient population, (elevated A1C is interesting as risk factor), however, I believe it would delay cases, due to need for providers wo are expert at performing and reading these US in the preop setting.

[Monica Douglas]

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?

In my practice, I have never performed a gastric US.

2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?

I think that performing gastric ultrasonography preoperatively would be helpful to guide the choice for anesthetic management in patient's with a history of elevated A1C. However, performing gastric US amongst this population would require a restructuring of our preoperative process. Who would perform the gastric US in preop? For patients who receive their preop physicals in their physician's office, how would we be notified in advance of the specific comorbidities in order to arrange a gastric US?

[clawry]

1. In your practice, have you ever performed gastric ultrasonography? If so, what were your reasons for doing one?

    I have never performed gastric ultrasonography, but I would love to learn how to do it!


2. After reading this article, do you think gastric ultrasonography preoperatively is important? Why or why not?


    I think that gastric ultrasonography would be a useful tool preoperatively especially in high risk aspiration patients like those in endoscopy. It is a quick and easy procedure once you become proficient at ultrasound. It may change the anesthetic choice from MAC to GA. Currently we intubate all high risk patients in GI. In certain cases, it may prompt us to place a pre-induction NGT to empty out the stomach. This was a great article and it will be interesting to see if we start doing these in practice!

[christine Velarde]

I have never preformed gastric ultrasonography, I think it would be a good idea to learn how to perform the ultrasound to help prevent aspiration.
2. I think we should do ultrasonography however the fast turnover time and perhaps habitus of the patient may prevent us from sonography. I think an NGT would be beneficial in the known obstruction cases prior to induction or go directly to intubation then the look and see that is often done.

[mary clothier]

1. I have never performed or heard of gastric ultrasonography, reading our colleagues entries no one else has either, may be a great addition to our practice, study to be done @ JH.
We do have a very "large" high risk patient population, reading this article we can now add patients with a 7% HgB A1c to our high risk population.

2. Gastric Ultrasonography pre-op could be a great addition to our evaluation and exam, particularly in our high risk patient population, guiding us a bit more in our clinical decision making and judgement, to intubate, protecting that greater than average @ risk for aspiration airway or not!

Great article, Thanks!

[Jessica Switzman]

I have not performed gastric ultrasonography but I think this could be useful especially with our population at JHU; especially in endoscopy and for MAC cases.
I resort to RSI with cricoid pressure for at risk pt and NGTs for known obstruction cases prior to induction.