The perioperative management of patients using glucagon-like peptide 1 receptor agonists remains a topic of debate. While several multisociety statements have been published recently, the recommendations vary significantly in terms of medication management and preoperative fasting protocols for these patients. This document represents a multidisciplinary consensus statement led by the Society for Perioperative Assessment and Quality Improvement (SPAQI). It provides updated recommendations based on a modified Delphi process and supported by a systematic review of the current literature. The recommendations address management of the glucagon-like peptide 1 receptor agonists perioperatively, and preoperative fasting times for both solids and liquids. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42023438624).

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are increasingly being used for glycemic control and weight management. One of their key mechanisms of action is thought to be delaying gastric emptying. This review explores the perioperative risks associated with GLP-1RAs use, particularly the increased risk of gastric content retention and pulmonary aspiration. Current evidence suggests that patients on GLP-1RAs should be considered at risk for having a full stomach during surgery. Recommendations include careful assessment of medication details, additional monitoring, and preventive measures such as pre-anesthesia gastric ultrasound and rapid sequence induction. Further research is needed to establish comprehensive guidelines for the perioperative management of GLP-1RAs users. Adverse events related to GLP-1RAs use during anesthesia should be thoroughly documented, which is essential to inform future guidelines and to enhance patient safety.

The global rise in obesity and type 2 diabetes mellitus (T2DM) presents significant challenges in musculoskeletal care, contributing to increased perioperative complications, impaired bone health, and compromised muscle function. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), initially developed for glycemic control in T2DM, have demonstrated substantial benefits in weight reduction and metabolic regulation. The purpose of this review is to understand the musculoskeletal biologic and clinical implications of GLP-1RAs.

Evidence suggests that GLP-1RAs may impact musculoskeletal health through anti-inflammatory effects, bone metabolism modulation, and alterations in muscle composition. GLP-1RAs may promote osteoblastogenesis while dampening osteoclast activity to maintain bone mineral density. The result on fracture risk is unclear. Additionally, while GLP-1RAs cause lean mass loss, GLP-1RAs appear to preserve skeletal muscle, reduce fatty infiltration, and enhance fiber formation and function. Further, GLP-1Rs are present in synovial tissue and cartilage, demonstrating downregulation of inflammatory molecules and chondrocyte apoptotic pathways, though clinical studies show variable effects in the setting of osteoarthritis. Overall, the heterogeneity in findings underscores the need for further research to delineate the long-term musculoskeletal effects of GLP-1RAs. Understanding the musculoskeletal impact of GLP-1RAs is critical for optimizing their integration into orthopedic practice. This review explores the orthopedic implications of GLP-1RAs, highlighting their biologic mechanisms and clinical effects on obesity-related joint inflammation and arthropathy, bone mineral density and fracture risk, and skeletal muscle preservation.

Preoperative gastric ultrasound allows non-invasive qualitative and quantitative assessment of gastric contents aiding in preoperative risk assessment. We hypothesized that appropriately fasted diabetic surgical patients taking GLP-1 agonists would have higher gastric volumes than those not taking GLP-1 agonists.

This prospective, observational cohort study enrolled diabetic patients undergoing elective surgery, comparing those taking (n = 106) and not taking (n = 100) GLP-1 agonists. The primary outcome was gastric volume assessed via gastric ultrasound in the right lateral decubitus position. Secondary outcomes included presence of a full stomach (solids/thick liquids or greater than 1.5 mL/kg clear liquid), need for surgery delay, Perlas grade, and occurrence of intraoperative aspiration. The impact of GLP-1 agonist type, duration of use, and timing of last dose on gastric volume was also examined.

Diabetic patients on GLP-1 agonists had significantly higher median gastric volumes compared to patients not on GLP-1 agonists (0.61 mL/kg vs 0.16 mL/kg, P < 0.001) and increased odds of a full stomach (OR 11.3, 95 % CI 5.2-24.7, P < 0.0001). GLP-1 agonist use correlated with higher Perlas grades (P < 0.001). Gastric volumes were significantly higher with GLP-1 agonist use within 7 days of surgery relative to use within 7-14 days or more than 14 days from surgery (P < 0.001 for both comparisons).

GLP-1 agonist therapy was associated with higher residual gastric volumes and higher risks of full stomachs in fasted diabetic patients. GLP-1 agonist use within 7 days of surgery was also associated with higher gastric volumes relative to holding therapy for over 7 days, supporting current consensus-based guidelines.

This article is intended as a brief review on the glucagon-like peptide-1 (GLP-1) agonist Semaglutide (Ozempic®, Rybelsus®, Wegovy®), an antidiabetic medication that has gained significant popularity in the United States for its role in long-term weight-loss management. While current research on GLP-1 agonists, including semaglutide, focuses primarily on their therapeutic effects in managing diabetes and obesity, information regarding their forensic and medicolegal significance is limited. Concerns related to GLP-1 agonists may arise due to their pharmacokinetics, potential drug-drug interactions, and side effects including hypoglycemia, which can be relevant in cases involving human performance, such as impaired driving, or in unexpected fatalities. Semaglutide additionally presents analytical challenges due to its large, highly charged molecular structure and potentially limited stability in whole blood, which may complicate its detection and quantification in forensic laboratories using common instrumentation. The development of robust analytical methods will be essential to account for its pharmacological effects and to address its potential role in intoxications or unexplained fatalities, especially in the context of misuse or off-label use for weight loss. A strong case can be made for the necessity of further research into the detection, quantification, and interpretation of semaglutide concentrations in forensic toxicology casework.

We investigated the effect of semaglutide, a glucagon-like peptide-1 (GLP-1) agonist therapy, on retained gastric contents during endoscopy through a retrospective case-control study.

We performed a retrospective case-control study to evaluate the effect of semaglutide on rates of retained gastric contents (RGC) visualized during esophagogastroduodenoscopy (EGD). Cases and controls were matched using multidimensional propensity score matching: age, gender, body mass index, and EGD indication. Pairs were analyzed using McNemar testing and Mann-Whitney non-parametric tests.

Of the patients on GLP-1 therapy at time of EGD, 12.5% had RGC, compared with 1.3% in the control group (confidence interval [CI] 7.2% to 17.7%, P < 0.0001). Approximately 23% of patients prescribed GLP-1 therapy for weight loss had RGC at time of EGD compared with the control group (CI 13.4% to 32.6%, P < 0.0001). Only 2.6% of patients prescribed GLP-1 therapy for diabetes had RGC at time of EGD compared with the control group (CI -0.9% to 6.1%, P = 0.5). Patients receiving GLP-1 therapy with RGC at time of EGD did not differ from non-RGC patients in dosing of GLP-1 agonist ( P = 0.23) or duration of GLP-1 agonist use prior to EGD ( P = 0.98).

Semaglutide use appears to increase risk of having retained gastric contents visualized during endoscopy. Patients on semaglutide for weight loss appear to have a greater risk of RGC compared with patients on semaglutide for glycemic control. This observation may have clinical implications for management of GLP-1 agonist use prior to endoscopy.

The use of glucagon-like peptide 1 receptor agonists has been associated with gastroparesis, but little is known about the risk of gastroparesis in those with obesity but without type 2 diabetes (T2D), and how that risk compares with other treatment modalities for obesity. This study aims to characterise the relationship between different treatment modalities for obesity and the risk of gastroparesis in a population without pre-existing T2D.

A retrospective cohort study using Merative MarketScan Research Databases of individuals with obesity who underwent treatment with semaglutide, bupropion-naltrexone or sleeve gastrectomy from 1 January 2018 to 31 December 2022. The incidence of gastroparesis diagnosis was evaluated using International Classification of Diseases, Version 10 codes. The risk of gastroparesis was compared between three intervention groups using Cox proportional hazards regression models.

Of the 55 460 individuals included, 36 990 (66.7%) were treated with semaglutide, 7369 (13.3%) with bupropion-naltrexone and 11 101 (13.7%) with sleeve gastrectomy. Gastroparesis rates among those treated with semaglutide versus bupropion-naltrexone versus sleeve gastrectomy were 6.5 per 1000 person-years (PY) vs 2.1 per 1000 PY vs 1.1 per 1000 PY, respectively. After adjusting for baseline characteristics, individuals treated with semaglutide had a higher risk of gastroparesis than those treated with bupropion-naltrexone (adjusted HR 3.33, 95% CI 2.27, 4.98) and sleeve gastrectomy (adjusted HR 6.14, 95% CI 3.94, 9.57).

There is an increased incidence of gastroparesis among individuals with obesity without T2D who are using semaglutide as compared with bupropion-naltrexone and sleeve gastrectomy. Understanding these potential side effects, though rare, may help guide personalised treatment regimens.

Clinical practice in patients at risk of pulmonary aspiration varies widely. However, data on actual management, decision-driving factors and controversial issues remain elusive.

We aimed to comprehensively review the management of patients at risk of pulmonary aspiration and identify controversies among anaesthesia professionals.

National interprofessional survey.

All anaesthesia departments in Switzerland.

The survey was distributed electronically to all members of the Swiss Society of Anaesthesiology and Perioperative Medicine, members of the Swiss Interest Group for Anaesthesia Nursing and all department heads in Switzerland.

None.

Consensus and controversies in clinical practice and management of patients at risk of pulmonary aspiration.

A total of 684 respondents were included in the final analysis (59 department heads, 366 consultants, 99 registrars, 160 nurse anaesthetists). The response rate from physicians was 47%. Consensus (>80% agreement or disagreement) was reached on 9/12 (75%) questions regarding preparation for rapid sequence induction (RSI), 6/13 (46%) regarding RSI practice and 3/8 (38%) regarding management of aspiration incidents. Major controversies included high-flow pre-oxygenation (55% agreement), the validity of modified RSI in adults (52% agreement), the primary use of video-laryngoscope (76% agreement) and management of apparent regurgitation. Subjective factors such as clinical presentation were considered more important than objective factors such as medical history, comorbidities or gastric ultrasound.

Across a wide range of experience and professional groups, we found a strong consensus on the indication and performance of 'traditional' RSI. However, clinical decision-making still relies heavily on subjective impressions, while newer risk stratification and management techniques remain controversial.

Perioperative management of patients receiving a glucagon-like peptide-1 receptor agonist (GLP-1 RA) remains challenging for the anesthesiologist. Despite the approval of GLP-1 RAs 2 decades ago, the recent reports of aspiration and postoperative pulmonary complications drew attention to this group of medications and resulted in multiple societal guidelines that would provide recommendations for anesthesiologists and proceduralists on the appropriate perioperative management of GLP-1 RAs. However, despite these guidelines and proposed options, there was a lack of adequate evidence to support holding versus continuing the medication, as well as data related to the role of gastric ultrasound in that decision-making process. The release of multiple societal guidelines and studies evaluating the impact of GLP-1 RAs on perioperative outcomes resulted in more controversy and uncertainty for the clinician anesthesiologist to follow. The ultimate goal for perioperative management of these medications is to evaluate an individual patient's risk of aspiration, rather than assuming the risk is low when holding the medication appropriately or high if not holding it. Furthermore, it is unclear whether holding these types of medicines or unnecessary postponing of surgery may result in adverse outcomes. In this narrative review, we present a summary of the existing literature on the topic with a focus on the risk of aspiration and a recommendation for perioperative management to include the utilization of gastric ultrasound for surgery patients based on their risks.

To assess rates of surgical complications and postoperative readmission in diabetic patients with and without active perioperative prescriptions for glucagon-like peptide-1 receptor agonist (GLP-1 RA) medications.

With the rapid growth of GLP-1 RA use in the United States, it is important to understand the potential effect of these drugs on surgical outcomes broadly.

In this retrospective, observational cohort analysis, patients with a diagnosis of type 1 or type 2 diabetes undergoing a surgical procedure at a multicenter quaternary-care health care system between February 2020 and July 2023 were included. Propensity score matching was performed between procedures in patients with and without an active GLP-1 RA prescription. The primary outcome was 30-day readmission, and secondary outcomes were documented dehiscence, infection, hematoma, and bleeding within 180 days after surgery.

Among 74,425 surgical procedures in 21,772 patients included in the analysis, 27.2% were performed in the setting of an active GLP-1 RA prescription. In 13,129 patients [48.0% men, 52.0% women; median (interquartile range) age, 67 (57, 75)], 35,020 procedures were propensity score matched. After matching, the active GLP-1 RA prescription group had a significantly reduced risk of 30-day readmission [relative risk (RR): 0.883; 95% CI: 0.789-0.987; P = 0.028; number needed to treat (NNT): 219; 95% CI: 191-257], postoperative wound dehiscence (RR: 0.711; 95% CI: 0.577-0.877; P = 0.001; NNT: 266; 95% CI: 202-391), and postoperative hematoma (RR: 0.440; 95% CI: 0.216-0.894; P = 0.023; NNT: 1786; 95% CI: 652-2416). No significant differences were seen in rates of infection and bleeding.

An active perioperative GLP-1 RA prescription in patients with diabetes was associated with significant reductions in risk-adjusted readmission, wound dehiscence, and hematoma, and no difference in infection and bleeding rates. Further study is warranted to elucidate any causal association.

Glucagon-like peptide-1-receptor agonists (GLP1-RAs) have been associated with greater retention of gastric contents, however, there is minimal controlled, population-based data evaluating the potential adverse effects of GLP1-RA in the periprocedural setting. We aimed to determine if there is increased risk of aspiration and aspiration-related complications after upper endoscopy in patients using GLP1-RAs.

We used a nationwide commercial administrative claims database to conduct a retrospective cohort study of patients aged 18 to 64 with type 2 diabetes who underwent outpatient upper endoscopy from 2005 to 2021. We identified 6,806,046 unique upper endoscopy procedures. We compared claims for aspiration and associated pulmonary adverse events in the 14 days after upper endoscopy between users of GLP1-RAs, dipeptidyl peptidase 4 inhibitors (DPP4is), and chronic opioids. We adjusted for age, sex, Charlson Comorbidity score, underlying respiratory disease, and gastroparesis.

We found that pulmonary adverse events after upper endoscopy are rare, ranging from 6 to 25 events per 10,000 procedures. When comparing GLP1-RAs with DPP4i, crude relative risks of aspiration (0.67; 95% CI, 0.25-1.75), aspiration pneumonia (0.95; 95% CI, 0.40-2.29), pneumonia (1.07; 95% CI, 0.62-1.86), or respiratory failure (0.75; 95% CI, 0.38-1.48) were not higher in patients prescribed a GLP1-RA. When comparing GLP1-RAs with opioids, crude relative risks were 0.42 (95% CI, 0.15-1.16) for aspiration, 0.60 (95% CI, 0.24-1.52) for aspiration pneumonia, 0.30 (95% CI, 0.19-0.49) for pneumonia, and 0.24 (95% CI, 0.13-0.45) for respiratory failure. These results were consistent across several sensitivity analyses.

GLP1-RA use is not associated with an increased risk of pulmonary complications after upper endoscopy compared with DPP4i use in patients with type 2 diabetes.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been increasingly prescribed for weight management in recent years. However, little is known about whether preoperative GLP-1 RA use is associated with a greater risk of complications after surgery.

To investigate whether preoperative GLP-1 RA use is associated with postoperative aspiration pneumonia among patients undergoing common surgical procedures.

This retrospective cohort study, conducted using MarketScan commercial claims databases, included patients who underwent 1 of 14 common surgical procedures from April 1, 2020, to September 30, 2022. Individuals who were younger than 18 years, underwent multiple surgical procedures, or had a preoperative history of pneumonia or acute respiratory failure in the 90 days preceding surgery were excluded. Data were analyzed from December 2023 to March 2024.

The primary outcome was aspiration pneumonia in the 30-day postoperative period. Multivariable logistic regressions were performed, adjusting for patient and surgical characteristics.

This study included 366 476 patients (median age, 53 years [IQR, 43-62 years]), of whom 56.4% were women. In the cohort, 5931 patients (1.6%) had a preoperative prescription for a GLP-1 RA. Patients using GLP-1 RAs were more likely to be female (3502 [59.0%] vs 203 288 [56.4%]) and diagnosed with both obesity and diabetes (2819 [47.5%] vs 24 635 [6.8%]) compared with nonusers. Adjusted analysis showed no significant differences in the odds of postoperative pneumonia (odds ratio, 0.78; 95% CI, 0.57-1.06; P = .12) between GLP-1 RA users and nonusers.

This cohort study found no significant association between the preoperative use of GLP-1 RAs and short-term postoperative aspiration pneumonia despite growing concerns about the adverse effects of these medications after surgery. This finding suggests that it may be beneficial to reassess the preoperative withholding guidelines for GLP-1 RAs.

The use of gut-hormone receptors agonists as new therapeutic options for obesity and some of its related comorbidities, such as type 2 diabetes, has resulted in an unprecedented efficacy in the medical management of people living with obesity (PLWO). Appraisal of the safety of these drugs is of utmost importance considering the large number of PLWO, and the potentially long exposure to these pharmacotherapies. In this narrative review we summarize the evidence on the safety of liraglutide, semaglutide, and tirzepatide as derived from randomized clinical trials conducted in adults living with obesity. Additionally, the safety of these drugs is put into perspective with that of other drugs currently approved for the treatment of PLWO. Overall, the available data support a favorable efficacy versus safety balance for gut-hormone hormone receptor analogues in the treatment of these subjects. Nonetheless, it should be acknowledged that in the context of a chronic disease that has reached epidemic proportions, data from randomized clinical trials aimed primarily at proving the efficacy of these drugs may have been insufficient to unveil all the safety issues. Thus, continuous surveillance on the adverse effects of liraglutide, semaglutide, and tirzepatide is required as we use these drugs in a broader population than that represented in currently available clinical trials.

Glucagon-like peptide-1 (GLP-1) is a hormone involved in glucose homeostasis and satiety regulation. The review highlights the importance of understanding the interplay between GLP-1 and gastric motility. This paper explores the intricate connection between GLP-1 and delayed gastric emptying, specifically gastroparesis, and its implications in the context of pulmonary aspiration during anesthesia along with the potential effects of GLP-1 medications on absorption of other medications. The findings noted in this paper serve as a catalyst for continued exploration into the intricate dynamics of GLP-1 and its implications in the context of perioperative care, aiming to enhance patient safety and optimize anesthesia practices. The inquiry suggests that an in-depth examination of this relationship is crucial for refining perioperative management strategies. It underscores the need for further research to elucidate the mechanisms involved and to establish guidelines that address the potential risks associated with GLP-1 modulation, particularly in patients undergoing anesthesia for various cardiac surgeries and procedures. Specifically in the context of cardiac interventions understanding the potential for delayed absorption of critical cardiac medications due to the influence of GLP-1 on gastric emptying is particularly important as drug absorption can play a crucial role for ensuring successful outcomes.

While ubiquity of glucagon-like peptide receptor agonists (GLP1-RAs) is rising, guidance from the gastroenterology societies and American Society of Anesthesiologist (ASA) remains in conflict on recommendations regarding preoperative holding before endoscopy. The aim of this study was to address this by evaluating the effect of GLP1-RAs on gastric retention during upper endoscopy.

This multicenter cross-sectional study included patients on confirmed GLP1-RAs receiving an endoscopy from 2021 to 2023. Demographics, prescribing practices, and procedure outcomes were captured. GLP1-RA management of preoperative holding was retroactively classified per ASA guidance. Multivariable logistic regression was performed to assess factors influencing retained gastric contents.

Of 815 patients, 70 (8.7%) had retained gastric contents on endoscopy of whom 65 (93%) had type 2 diabetes mellitus. Only 1 (1.4%) of these patients required unplanned intubation, and none had aspiration events. Those with GLP1-RA held per ASA guidance (406, 49.8%) were less likely to have retained contents (4.4% vs 12.7%, P < 0.001), but there were no significant differences to intubation (0% vs 2%, P = 0.53) or aborting procedure rates (28% vs 18%, P = 0.40) due to gastric retention. On multivariable analysis, likelihood of food retention increased 36% (95% confidence interval 1.15-1.60) for every 1% increase in hemoglobin A1C after adjusting for GLP1-RA type and preoperative medication hold.

In this multicenter study, very low rates of retained gastric contents were seen during endoscopy in patients on GLP1-RAs and most were in patients with type 2 diabetes mellitus. Our findings suggest an individualized approach rather than universal preoperative holding of medications before endoscopy.

The GLP-1 receptor-based agonists (GLP-1RAs) and SGLT2 inhibitors (SGLT2i) are major twenty first century breakthroughs in diabetes and obesity medicine but there are important safety considerations regarding the perioperative and periprocedural management of individuals who are treated with these agents. GLP-1RAs have been linked to an increased risk of retained gastric contents and pulmonary aspiration while SGLT2i can be associated with diabetic ketoacidosis. This manuscript provides a narrative review of the available evidence for perioperative and periprocedural risks in people prescribed GLP-1RAs and SGLT2i. The authors provide expert opinion-driven recommendations and algorithms on how to safely manage GLP-1RAs and SGLT2i under perioperative/periprocedural settings.

» Obesity is a public health concern, with 41.9% of the US population classified as obese. Obesity increases the risk of chronic disease, type II diabetes, cardiovascular diseases, etc., leading to increased morbidity and mortality. Obesity has been identified as an independent risk factor of postoperative complications, including infection and impaired wound healing, following elective surgery. In total joint arthroplasty, it has been well elucidated that obese patients are predisposed to higher rates of postoperative complications, longer hospital stays, and increased cost of stay.» Obesity is influenced by the interplay between many societal, behavioral, and socioeconomic factors and requires a multidisciplinary approach to treatment. The patient's care team should be well versed in nutritional counseling, behavioral health counseling, medication management, and surgery to allow for a comprehensive approach.» Orthopaedic surgeons, dietitians, nutritionists, weight-loss physicians, and bariatric surgeons all play a critical role in treating this patient population. This review highlights the roles of these practitioners in developing an interdisciplinary framework to help patients with hip and knee arthritis lose weight before joint replacement surgery. Not only will this afford more patients the quality-of-life benefits that come with a hip or knee replacement but will also serve to decrease the complication rates associated with this patient cohort.» The aim of this review was to educate orthopaedic surgeons on various strategies that can be used to best optimize these patients for successful joint replacement surgery.

Diabetes mellitus (DM) is a prevalent condition that requires careful management in the perioperative setting to reduce surgical risks and optimize patient outcomes. The preoperative care of diabetic patients is complex because glucose control must be balanced with minimizing hypoglycemic or hyperglycemic events during surgery. A variety of diabetic medications such as insulin, dipeptidyl-peptidase-4 inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, and biguanides such as metformin present unique challenges and considerations due to their different mechanisms, benefits, and potential adverse effects. In recent years, professional organizations have developed recommendations on the perioperative management of these therapies, although there remain some variations in guidelines related to medication cessation and dosage adjustments. Standardized protocols in preoperative DM care remain a topic of interest to ensure consistent and safe practices across healthcare settings, and further collaborative research efforts could provide clarity and consensus in managing this diverse patient population.

The objective of this study was to provide an overview of guidelines and practices to support healthcare professionals in delivering improved preoperative care for diabetic patients. This initiative aims to enhance surgical outcomes and minimize the occurrence of complications.

This is a comparative review that provides a systematic comparison of the similarities and differences in the guidelines and recommendations of three professional organizations along with Hamad Medical Corporation. All guidelines were from official websites including Hamad Medical Corporation.

Although the reviewed guidelines for the preoperative care of diabetes patients share some similarities, there are also a number of differences due to outdated data and expert opinions, and therefore differ in practices around the world. While the key elements are agreed upon, more research and global collaboration are needed to create consistent guidelines and improve patient outcomes.

Surgeons are likely to encounter patients on GLP-1 receptor agonists (GLP-1RAs) and should be aware of any associated risks or complications. Here we review the existing literature on GLP-1RA use as it pertains to non-bariatric surgeons.

A systematic review was conducted following PRISMA 2020 guidelines. Three databases were queried for articles discussing the use of GLP-1RAs in a surgical context. Articles went through two rounds of manual screening.

21 articles were included in analysis, which found that pre-operatively, GLP-1RAs can aid patients in meeting the BMI threshold for surgery. Peri-operatively, GLP-1RAs were associated with improved glycemic control and lower intraoperative insulin use. Complications such as delayed gastric emptying and increased rates of hypoglycemic events were reported.

Surgeons may leverage GLP-1RAs to help prepare patients for surgery and should understand potential surgical complications associated with the use of these medications and to screen preoperative patients appropriately.

Pulmonary aspiration is an adverse event with high morbidity and mortality. Despite fasting for > 8 hr, some patients still have residual gastric volume and are thus at risk of aspiration. We aimed to determine the accuracy of gastric ultrasound in assessing residual gastric content in patients undergoing upper gastrointestinal endoscopy.

In a prospective cohort study, we performed gastric ultrasound immediately before upper gastrointestinal endoscopy in a sample of 294 patients. We categorized the ultrasound results as high risk of aspiration when the fluid volume was > 1.5 mL·kg-1 or when there was thick/solid content. We applied Spearman's test to determine the correlation between aspirated volume and ultrasound-estimated volume using three mathematical models. We assessed the method's accuracy by calculating its sensitivity and specificity.

We included 282 patients in the analysis. The incidence of residual gastric contents was 5%. There were no aspiration events. Prokinetic use (relative risk [RR], 7.5; 95% confidence interval [CI], 1.9 to 29.1; P < 0.01), previous stroke (RR, 4.0; 95% CI, 1.2 to 13.6; P = 0.02), and male sex (RR, 3.3; 95% CI, 1.2 to 9.4; P = 0.02) were significantly more frequent among those with residual gastric content. The ultrasonography's specificity and sensitivity to predict gastric content at risk of aspiration were 100% and 77%, respectively, with a positive predictive value of 100% and a negative predictive value of 99%.

Ultrasonography was an effective way to assess residual gastric content, which can help improve patient safety.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs), also known as incretin mimetics, have significantly revolutionized the treatment of type 2 diabetes mellitus (T2DM) and obesity worldwide, far exceeding initial expectations regarding their global prescription. This class of medications has demonstrated weight losses of up to 20 % of baseline body weight. Beyond their proven benefits in T2DM and obesity, GLP-1RAs, as well as dual and triple agonists (GLP-1/GIP/glucagon), are being investigated for their effects on conditions such as metabolic-associated steatotic liver disease, various cardiovascular disorders, neurocognitive impairments, and certain addictions. These emerging effects appear to be linked not only to their metabolic action but also to their ability to modulate the chronic inflammatory state underlying these pathologies.

Glucagon-like peptide-1 receptor agonist (GLP-1RA) therapies are increasingly used for the treatment of type 2 diabetes mellitus and obesity. Despite growing awareness of potentially increased risk of pulmonary aspiration due to delayed gastric emptying, the risks and benefits of their perioperative use in patients undergoing cardiac procedures remains unexplored. A scoping review was performed to investigate the perioperative GLP-1RA use in patients undergoing cardiac procedures and recommendations.

PubMed and Ovid MEDLINE were searched up to April 2024 to identify English-language studies on the perioperative use of weekly and daily dosed GLP-1RAs in adult patients undergoing cardiac procedures (including cardiac surgery, trans-oesophageal echocardiograms, and cardiac catheterisation procedures).

Three studies were identified, which investigated daily dosed GLP-1RAs in patients undergoing cardiac surgery. No studies were found investigating GLP-1RA use in cardiac catheterisation or trans-oesophageal echocardiograms procedures, and none which specifically examined risk of pulmonary aspiration in patients using GLP-1RAs undergoing cardiac procedures.

GLP-1RAs are beneficial for perioperative weight loss, glycaemic control, and cardiovascular health. Existing guidelines and consensus recommendations are highly contradictory on perioperative GLP-1RA management. Although no known published case reports exist to date of pulmonary aspiration in patients using GLP-1RAs undergoing cardiac procedures, non-cardiac surgical literature strongly suggests that patients are at theoretical risk and a cautious approach is advised in the absence of robust evidence informing recommendations for optimal withholding periods.

With the growing use of glucagon-like-peptide-1 (GLP-1) receptor (GLP-1R) agonists as anti-obesity medication it is becoming increasingly important to examine its consequences in the peri-operative period. GLP-1R agonists are known for their effects of glucose-lowering and gastroparesis the latter causing some safety concerns regarding induction of anaesthesia, more specifically the risk of pulmonary aspiration. This article gathers the available evidence on this subject in addition to the already established guidelines. Current evidence makes us assume there is indeed an increased level of gastroparesis, but there are no studies to date with evidential confirmation of a presumed elevated risk of pulmonary aspiration. Future perspectives should focus on the actual risk of pulmonary aspiration and the possible implementation of ultrasound in the preoperative assessment.

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are known to cause delayed gastric emptying; however, the effect on clinical outcomes during upper endoscopy and colonoscopy remains unclear. We conducted a meta-analysis to reconcile the data.

Online databases were searched for studies evaluating GLP-1RAs versus a control group (no GLP-1RAs) in patients undergoing endoscopy. The outcomes of interest were rate of retained gastric contents (RGCs), aborted procedures, aspiration events, and subjective bowel preparation quality. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random-effects model.

Twenty-three studies with 77,152 patients (4449 in the GLP-1RA arm and 72,703 in the control arm) were included. Mean patient age ranged from 47.6 to 72 years, and 58.4% were women. As compared with the control group, the GLP-1RA group had higher odds of RGCs (OR, 15.39; 95% CI, 4.65-50.99; P < .01) and aborted procedures (OR, 13.86; 95% CI, 4.42-43.43; P < .01). No significant differences were observed between the 2 groups in terms of aspiration events (OR, 21.06; 95% CI, .13-3379.01; P = .24) and subjective bowel preparation quality (OR, .94; 95% CI, .67-1.31; P = .83).

Although statistical significance was reached in terms of visible RGCs and early termination of endoscopies in patients on GLP-1RAs, these events were overall rare. GLP-1RAs do not appear to pose significant risk, as the odds of developing aspiration were comparable in the 2 groups.

Obesity is one of the greatest public health concerns in the United States and has reached an epidemic scope over the past few decades. Plastic surgery in patients with obesity has been linked to higher complication rates both before and after weight loss. This article discusses the evolution and landscape of antiobesity medications as they apply to plastic surgery. Although bariatric surgery has been effective in long-term treatment, new pharmacologic advances in glucagon-like peptide-1 agonists, such as semaglutide, have demonstrated promising effectiveness. These medications pose several unique challenges, particularly with regard to perioperative management and risk of weight regain after discontinuation. An understanding of these new pharmacologic agents is crucial for plastic surgeons, who treat patients with obesity.

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

GlP-1 receptor agonists are a class of medications that are becoming increasingly popular. Large trials have shown that their use provides reliable weight loss in obese patients and improved glycemic control in diabetic patients. Its use also has broader implications for overall metabolic health and has been shown to improve cardiovascular outcomes in high-risk populations. Glucagon-like peptide 1 receptors cause multiple effects in the body through stimulation of receptors expressed in a broad range of tissues including the pancreas, liver, gastrointestinal tract, kidneys, heart, endothelium, muscle, and brain. For the anesthesia professionals the effects of these medications on gastric emptying is important.

Recent evidence suggests that perioperative semaglutide use is associated with increased residual gastric content (RGC) and risk of bronchoaspiration under anesthesia. We compared the occurrence of increased RGC in semaglutide users and non-users undergoing esophagogastroduodenoscopy to define the time interval at which RGC becomes comparable between groups.

This was a single-center retrospective electronic chart review at a tertiary hospital. Patients undergoing esophagogastroduodenoscopy under deep sedation/general anesthesia between July/2021-July/2023 were included and divided into two (SG = semaglutide, NSG = non-semaglutide) groups, according to whether they had received semaglutide within 30 days prior to the esophagogastroduodenoscopy. Univariate and multivariate logistic regression were performed to explore which factors were associated with increased RGC, defined as any amount of solid content, or > 0.8 mL/Kg (measured from the aspiration/suction canister) of fluid content.

Among the 1094 (SG = 123; NSG = 971) patients included, increased RGC was observed in 56 (5.12%), being 25 (20.33%) in the SG and 31 (3.19%) in the NSG (p < 0.001). Following weighted analysis, the presence of ongoing digestive symptoms (nausea/vomiting, dyspepsia, and/or bloating/abdominal distension) pre-esophagogastroduodenoscopy [OR = 15.1 (95% confidence interval (CI) 9.85-23.45)] and the time intervals of preoperative semaglutide interruption < 8 days [OR 10.0 (95%CI 6.67-15.65)] and 8-14 days [4.59 (95%CI 2.91-7.37)] remained significantly associated with increased RGC. Following inverse probability treatment weighting adjustment including a composite variable 'time intervals of semaglutide interruption' versus 'presence of ongoing digestive symptoms', only time intervals > 14 days and without digestive symptoms showed no association with increased RGC [OR = 0.77 (95%CI 0.22-2.01)].

Perioperative semaglutide use is associated with increased RGC in patients undergoing elective esophagogastroduodenoscopy. Preoperative discontinuation of > 21 days and > 14 days in patients with and without ongoing digestive symptoms, respectively, resulted in RGC similar to non-semaglutide users.

This review investigates the side effects of glucagon-like peptide-1 receptor agonists (GLP-1RAs) like liraglutide, semaglutide, and tirzepatide, medications known for their efficacy in promoting weight loss among individuals with obesity. The rationale is rooted in understanding the balance between their therapeutic benefits and associated risks.

This was a comprehensive clinical review, including systematic reviews, meta-analyses, randomized controlled trials (RCTs), and cohort studies. Data were extracted from databases such as PubMed, Scopus, Embase, MEDLINE, and Google Scholar, focusing on the tolerability, severity, and risks of these medications.

GLP-1RAs demonstrated significant weight loss outcomes. In clinical trials, liraglutide showed a placebo-corrected weight loss of around 5 %, semaglutide 12 %, and tirzepatide 18 %. Common side effects were predominantly gastrointestinal, including nausea, diarrhea, constipation, and vomiting. Rare serious adverse events included gallbladder disorders and acute pancreatitis. In, addition, multiple studies identify new risks associated with GLP-1RAs including increased aspiration risk during anesthesia due to delayed gastric emptying and challenges with bowel preparation for colonoscopies.

While GLP-1RAs are effective in managing obesity, their use is associated with gastrointestinal side effects and rare but serious adverse events. The findings underscore the importance of individualized dosing and thorough patient assessment. Continuous research and vigilant monitoring are essential to optimize their safe use. Further studies are needed to refine guidelines, particularly regarding new concerns such as delayed gastric emptying and its implications for anesthesia.

We aimed to investigate the association between Glucagon-like-peptide-1 receptors agonists (GLP1-RA) use and gastric residue on esophagogastroduodenoscopy (EGD).

A multicenter, retrospective study included all EGDs conducted across seven gastroenterology departments. EGDs with the diagnosis of "poor preparation" or described as a poor preparation in the endoscopist's report were considered as gastric residue.

120,879 EGDs were included in the analysis. Of these, 1671 patients treated with GLP1-RA were compared to 119,208 without GLP1-RA treatment. Of the GLP1-RA group, 93 (5.6 %) had gastric residue compared to 2327 (2.0 %) among the non-GLP1-RA group (p < 0.001). Sup-group analysis: 71 (6.2 %) of the 1141 DM patients treated with GLP1-RA compared to 307 (3.0 %) of the 10,152 DM patients without GLP1-RA treatment (p < 0.001). Additionally, 22 (4.2 %) of 503 non-DM patients treated with GLP1-RA had gastric residue compared to 2065 (2.0 %) of the non-DM non-GLP1-RA group (n = 109,056) (p < 0.001). In multivariate analysis, DM and GLP1-RA were both found to be independent risk factors for excess gastric residue.

Our results may have important clinical relevance for EGD preparation among GLP1-RA treated patients, either requiring a longer fasting time prior to EGD or holding the medication prior to EGD according to the half-life of the drug.

Patients with hyperglycemia, thyroid dysfunction, and adrenal insufficiency face increased perioperative risk, which may be mitigated by appropriate management. This review addresses preoperative glycemic control, makes evidence-based recommendations for the increasingly complex perioperative management of noninsulin diabetes medications, and provides guideline-supported strategies for the perioperative management of insulin, including suggested indications for continuous intravenous insulin. The authors propose a strategy for determining when surgery should be delayed in patients with thyroid dysfunction and present a matrix for managing perioperative stress dose corticosteroids based on the limited evidence available.

Background: The increased popularity and ubiquitous use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for the treatment of diabetes, heart failure, and obesity has led to significant concern for increased risk for perioperative aspiration, given their effects on delayed gastric emptying. This concern is highlighted by many major societies that have published varying guidance on the perioperative management of these medications, given limited data. We conducted a scoping review of the available literature regarding the aspiration risk and aspiration/regurgitant events related to GLP-1 RAs. Methods: A librarian-assisted search was performed using five electronic medical databases (PubMed, Embase, and Web of Science Platform Databases, including Web of Science Core Collection, KCI Korean Journal Database, MEDLINE, and Preprint Citation Index) from inception through March 2024 for articles that reported endoscopic, ultrasound, and nasogastric evaluation for increased residual gastric volume retained food contents, as well as incidences of regurgitation and aspiration events. Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. Results: Of the 3712 citations identified, 24 studies met eligibility criteria. Studies included four prospective, six retrospective, five case series, and nine case reports. The GLP-1 RAs reported in the studies included semaglutide, liraglutide, lixisenatide, dulaglutide, tirzepatide, and exenatide. All studies, except one case report, reported patients with confounding factors for retained gastric contents and aspiration, such as a history of diabetes, cirrhosis, hypothyroidism, psychiatric disorders, gastric reflux, Barrett's esophagus, Parkinson's disease, dysphagia, obstructive sleep apnea, gastric polyps, prior abdominal surgeries, autoimmune diseases, pain, ASA physical status classification, procedural factors (i.e., thyroid surgery associated with risk for nausea, ketamine associated with nausea and secretions), and/or medications associated with delayed gastric emptying (opioids, anticholinergics, antidepressants, beta-blockers, calcium channel blockers, DPP-IV inhibitors, and antacids). Of the eight studies (three prospective and five retrospective) that evaluated residual contents in both GLP-1 users and non-users, seven studies (n = 7/8) reported a significant increase in residual gastric contents in GLP-1 users compared to non-users (19-56% vs. 5-20%). In the three retrospective studies that evaluated for aspiration events, there was no significant difference in aspiration events, with one study reporting aspiration rates of 4.8 cases per 10,000 in GLP-1 RA users compared to 4.6 cases per 10,000 in nonusers and the remaining two studies reporting one aspiration event in the GLP-1 RA user group and none in the non-user group. In one study that evaluated for regurgitation or reflux by esophageal manometry and pH, there was no significant difference in reflux episodes but a reduction in gastric acidity in the GLP-1 RA user group compared to the non-user group. Conclusions: There is significant variability in the findings reported in the studies, and most of these studies include confounding factors that may influence the association between GLP-1 RAs and an increased risk of aspiration and related events. While GLP-1 RAs do increase residual gastric contents in line with their mechanism of action, the currently available data do not suggest a significant increase in aspiration and regurgitation events associated with their use and the withholding of GLP-1 RAs to reduce aspiration and regurgitation events, as is currently recommended by many major societal guidelines. Large randomized controlled trials (RCTs) may be helpful in further elucidating the impact of GLP-1 RAs on perioperative aspiration risk.

To assess whether use of glucagon-like peptide-1 (GLP-1) receptor agonists before upper gastrointestinal endoscopy is associated with increased risk of pulmonary aspiration or discontinuation of the procedure compared with sodium-glucose cotransporter-2 (SGLT-2) inhibitors.

Cohort study.

Two deidentified US commercial healthcare databases.

43 365 adults (≥18 years) with type 2 diabetes who used a GLP-1 receptor agonist or SGLT-2 inhibitor within 30 days before upper gastrointestinal endoscopy.

The primary outcome was pulmonary aspiration on the day of or the day after endoscopy, defined using diagnostic codes. The secondary outcome was discontinuation of endoscopy. Risk ratios and corresponding 95% confidence intervals (CIs) were estimated after fine stratification weighting based on propensity score.

After weighting, 24 817 adults used a GLP-1 receptor agonist (mean age 59.9 years; 63.6% female) and 18 537 used an SGLT-2 inhibitor (59.8 years; 63.7% female). Among users of GLP-1 receptor agonists and SGLT-2 inhibitors, the weighted risk per 1000 people was, respectively, 4.15 and 4.26 for pulmonary aspiration and 9.79 and 4.91 for discontinuation of endoscopy. Compared with SGLT-2 inhibitor use, GLP-1 receptor agonist use was not associated with an increased risk of pulmonary aspiration (pooled risk ratio 0.98, 95% CI 0.73 to 1.31), although it was associated with a higher risk for discontinuation of endoscopy (1.99, 1.56 to 2.53).

In this comparative cohort study, no increased risk of pulmonary aspiration during upper gastrointestinal endoscopy was observed among adults with type 2 diabetes using GLP-1 receptor agonists compared with SGLT-2 inhibitors within 30 days of the procedure; however, GLP-1 receptor agonists were associated with a higher risk of discontinuation of endoscopy, possibly owing to a higher risk of retained gastric content. In the absence of evidence from randomized trials, these findings could inform future practice recommendations on the preprocedural protocol for patients requiring endoscopy.

The availability of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) such as liraglutide and semaglutide, and a GLP-1 and glucose dependent insulinotropic polypeptide coagonist (tirzepatide) represents a paradigm shift in the management of both type 2 diabetes and obesity. There is now considerable attention, including in the public media, on the effect of both long-acting and short-acting GLP-1RAs to delay gastric emptying. Although slowed gastric emptying is integral to reducing post-prandial blood glucose responses in type 2 diabetes, marked slowing of gastric emptying might also increase the propensity for longer intragastric retention of food, with a consequent increased risk of aspiration at the time of surgery or upper gastrointestinal endoscopy. This Personal View summarises current knowledge of the effects of GLP-1 and GLP-1RAs on gastrointestinal physiology, particularly gastric emptying, and discusses the implications for the development of sound pre-operative or pre-procedural guidelines. The development of pre-procedural guidelines is currently compromised by the poor evidence base, particularly in relation to the effect of long-acting GLP-1RAs on gastric emptying. We suggest pre-procedural management pathways for individuals on GLP-1RA-based therapy and discuss priorities for future research.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) promote weight loss by suppressing appetite, enhancing satiety, regulating glucose metabolism, and delaying gastric motility. We sought to determine whether GLP-1 RA use could affect medical procedures such as EGD.

We conducted a retrospective study of 35,183 patients who underwent EGD between 2019 and 2023, 922 of whom were using a GLP-1 RAs. Data were collected regarding demographics, diabetes status, retained gastric contents during EGD, incidence of aborted EGD, and necessity for repeat EGD.

GLP-1 RA use was associated with a 4-fold increase in the retention of gastric contents (P < .0001), 4-fold higher rates of aborted EGD (P < .0001), and twice the likelihood of requiring repeat EGD (P = .0001), even after stratifying for the presence of diabetes.

GLP-1 RA use can lead to delayed gastric emptying, affecting EGD adequacy regardless of the presence of diabetes, and may warrant dose adjustment to improve the safety and efficacy of these procedures.

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become one of the most popular medications for patients with diabetes and obesity. Due to their effects on gut motility via central or parasympathetic pathways, there have been concerns about an increased incidence of retained gastric contents and risk of aspiration in the perioperative period. Hence, the American Society of Anesthesiologists (ASA) recommends holding GLP-1 RAs on the procedure day or a week before the elective procedure based on the respective daily or weekly formulations, regardless of the dose, indication (obesity or diabetes), or procedure type. On the contrary, the American Gastroenterological Association (AGA) advises an individualized approach, stating that more data are needed to decide if and when the GLP-1 RAs should be held prior to elective endoscopy. Several retrospective and prospective studies, along with meta-analyses, have been published since then evaluating the role of GLP-1 RAs in patients scheduled for endoscopic procedures. In this review, we discuss the current clinical guidelines and available studies regarding the effect of GLP-1 RAs on GI endoscopies.