October FY24

[A Schutter]

This months Journal Club comes from Nanciann Kean, CRNA. She chose an excellent article regarding the hot topic of GLP-1 agonists named: Are Serious Anesthesia Risks of Semaglutide and Other GLP-1 Agonists Under-Recognized? Case Reports of Retained Solid Gastric Contents in Patients Undergoing Anesthesia

Here is a link to the article.

Questions to engage discussion:

1. GLP-1's have been used for awhile (Exenatide was approved by the FDA in April 2005) and is there a significant increase in aspiration data since 2005? What have you been seeing in the operating rooms and does it follow with current ASA guidelines?

2. Do you believe it reasonable to utilize POCUS to determine gastric contents to guide your management with patients on these medications vs intubating everyone who has one of the GLP-1 Agonist medications listed on their chart? Would it be prudent to amend JHU Guidelines and have our providers learn POCUS techniques for this patient population and then make an informed decision with plan of care based on patient presentation on day of surgery?

[sjsimmons]

1. I personally have not yet cared for a patient taking a GLP-1 agonist pre-procedure but I think it is important to do our best to prevent the potential of aspiration due to gastroparesis. This may involve holding the GLP-1 agonist for a certain amount of time pre-procedure or switching to a clear liquid diet for 1-2 days prior to a procedure. This, of course, also requires effective communication with the patient and surgical team. In addition, patients on GLP-1 agonists are likely not good candidates for an LMA or deep sedation.

2. I believe POCUS would be a great skill for all CRNAs to have, whether it be for assessment of gastric contents prior to surgery or intra-op cardiac assessment. I recently attended the AANA Annual Congress in Seattle where a speaker presented about POCUS. He purchased a butterfly ultrasound that is small and portable and connects to your iPhone/iPad. He uses it daily in his clinical practice to assess gastric content, insert PIV and arterial lines, assess intubation success/ETT placement, assess cardiac function, perform nerve blocks, perform bladder scans, etc. He also uses it to teach SRNAs these techniques. POCUS is a simple skill to learn but could help guide our decision and management of patients on GLP-1 agonists.

[Soo-Ok Kim]

1. I have seen some of ambulatory care centers adapted ASA guideline related to a GLP-1 agonist use. In Hopkins, I had a pt with this medication for semi elective surgical procedure and the attending, regional anesthesia trained, was able to perform POCUS at the bedside to guide the anesthetic approach for airway choice.

2. I think it is reasonable to use POCUS to assess any available US guided clinical information including the assessment of gastric content. However, I am not certain if it is practical in many operative setting currently with the availability of US machine, the provider's competency of reading as well as the production pressure. In my opinion, it is more practical to guide pt preoperatively when to withhold the medication.
On the other hands, it is great idea for us to learn POCUS technique to utilize in many clinical setting.

[nanci]

1. I haven't seen an increase in the data for aspirations but knowingly not up to date on recent data. We recently did an ECT procedure, and the patient was on a GLP-1 agonist. We discovered the change and having had her started on the medication after the procedure when she had such copious secretions and after suctioning still heard that gurgle of fluid (presumed in her esophagus).

2. I'd like to learn and use POCUS for preop assessments on this patient population. Belief that the more we do, the quicker and more reliable the information we obtain from this point of care procedure will help guide our practice and be safer for our patients or at the least help appropriately manage, in real time, their condition(s). It's another way to bill for our services also helping to increase revenue into the department. I think the overall costs associated with obtaining individual units for use in the different areas might be recouped with billing, but it is a process and the wheels at our institution do not always move quickly when making change. We would still be held to departmental policy so if using POCUS to determine gastric contents our policy would need to be amended to allow us to deviate from current ASA Guidelines that we follow.

[Jessica Hadley]

1. I'm not sure about aspiration data, however I have seen an increased number of patients presenting for surgery who are taking GLP-1 agonists. Some of these patients were instructed correctly to hold these medications appropriately while others were not.

2. I think using POCUS for these patients could be a useful tool to determine aspiration risk preoperatively. However, POCUS is only useful if there is a provider who is skilled in US. I don't believe currently there are very many members of our depatrment who are proficient in POCUS. I would definitely be interested in learning this.

[Wai-Ling Lo]

It is such a coincidence that this topic was discussed in the most recent Grand round. This really validates the relevance of this matter.

1. I am not aware of a significant increase in aspirate data, but I too may not be too updated on it. However, I am definitely seeing more pts on GLP-1 agonist. Some are fasting according to ASA guidelines but not all. I remembered vividly that after an uneventful intubation of a diabetic pt who was on GLP-1 agonist, I got 700mL of gastric content from OG tube!!! That was my first awareness of this issue.

2. I too would like to learn how to utilize POCUS to determine gastric contents. Then our plan of care will not be a guessing game. However, change is a process that requires tremendous research/data support, risk/benefit assessment, and cost analysis. Like Nanci mentioned, it will be a long process. Hopefully with AI and more portable handheld ultrasound device, POCUS will be more affordable and easier to learn and use.

[aileenm4]

1. in pediatrics I have yet to encounter a patient on any of htese meds, however with the increase in morbid obesity in children and young teens I wonder if we will see this being used for peds patients
2. I do tink POCUS could be a valuable tool for all preop fasting and gastric volume assessments, recently we used this for a patient who was drinking the bowel prep up till 2 hours before and she had a large amount of volume present so we deayed the case

[Katya]

1. I have seen increased number of patients taken GLP-1 agonists in outpatient settings. I don't know about any data about increase of aspiration in these patients, but they are definitely at higher risk for it. We did cansel few cases foe elective surgery because patients did not stop their medications as advised.
2. I think POCUS can be a valuable tool for anesthesia provider to check patients that have higher risk of full stomach.

[kels]

1. GLP-1's have been used for awhile (Exenatide was approved by the FDA in April 2005) and is there a significant increase in aspiration data since 2005? What have you been seeing in the operating rooms and does it follow with current ASA guidelines? I have not encountered Pt's on these drugs currently. If they ever took the drug it was in the far far past

2. Do you believe it reasonable to utilize POCUS to determine gastric contents to guide your management with patients on these medications vs intubating everyone who has one of the GLP-1 Agonist medications listed on their chart? Would it be prudent to amend JHU Guidelines and have our providers learn POCUS techniques for this patient population and then make an informed decision with plan of care based on patient presentation on day of surgery? POCUS could be a valuable tool for all preop fasting and gastric volume assessments

[Amy Swank]

1. I have seen many more patients using GLP-1 angonists in the ambulatory setting. And even though they have been advised, correctly, to stop 7 days before receiving anesthesia, many still state a feeling of fullness and bloating the morning of surgery. This has necessitated a change in several plans of anesthesia to RSI, GETA and the risks that that involves. Several GI patients have full stomachs when endoscoped. I am unaware of the aspiration data with the increase in the use of these drugs - I think we are all learning it now.

2. I think the use of POCUS would be a valuable assessment tool and would absolutely help determine risk of this patient population. I think that the likelihood of acquiring these tools at the bedside would be the limiting factor since we can barely find MAC blades videolyaryngoscopes when needed for intubation. However, I hear that there is the ability to use portable ultrasound through our iPhones! That would be convenient and accessible. I wonder if we will be compensated for something like that?

[Benjamin Waldbaum]

1.) I think the first question may not fully account for the great increase in usage of these medications. In this month's Journal of the American Pharmacist Association there is an article specifically about this that states "Between 2014 and 2018, only Trulicity and Victoza exceeded 5000 annual users. Ozempic users increased from 569 in 2019 to 7667 in 2020. Use accelerated with more than 13,310 users in 2021 to surpass Trulicity. Ozempic count was 22,891 in 2022. Wegovy rose from 989 in 2021 to 2992 in 2022. Mounjaro increased to 1508 users in 2022." So while the medications were around, their use is greatly increasing over the last 2-3 years.

2. Additional data points such as a POCUS can be helpful in certain circumstances where the patient did hold their dose and still have gastric symptoms. It would be helpful for JHU to have this device available and that policies align with this clinical reality.