GLP-1RAs-and-Anesthesia-A-Guide-to-Safe-Practices [Autosaved].pptx

anesthesia consideration in patient scheduled to OR with history of chronic medication
GLP-1RAs

1. GLP-1RAs and Anesthesia: A Guide to Safe Practices This presentation will explore the growing use of GLP-1 Receptor Agonists (GLP-1RAs) in patients undergoing anesthesia, highlighting key considerations and best practices for perioperative care. We will delve into the mechanisms of action, clinical applications, and potential implications for anesthesia, along with the role of ultrasound in evaluating gastric emptying and improving patient safety. by Zenat Eldadamony Lecturer of Anesthesia &pain management Mansoura University

2. Overview of GLP-1 Receptor Agonists (GLP-1RAs) Mechanism of Action Endogenous GLP-1 is a gut-derived incretin hormone that reduces glycaemia by stimulating insulin production and secretion from pancreatic beta cells and by reducing glucagon secretion from alpha cells Therapeutic Uses GLP-1RAs are primarily used for type 2 diabetes management, but their applications are expanding to include weight management , and cardiovascular disease prevention

3. Common GLP-1 Agonists .

4. Cardiovascular effects and Clinical Applications expression of GLP-1 receptors in the sinoatrial node cardioprotective mechanisms are poorly understood. Animal studies showed increases in myocardial metabolic efficiency of glucose usage, lower vascular resistances in pulmonary and systemic circulations, and activation of ischemic preconditioning pathways Potential Anesthetic Considerations BESIDE The ability of GLP-1RAs to affect blood sugar levels and delay gastric emptying poses potential challenges in the perioperative setting. WE should consider increase heart rate and arrythmia

5. Gastrointestinal side-effects The most commonly reported side-effects of GLP-1 RAs are gastrointestinal, such as nausea, vomiting, and diarrhoeae Nausea and vomiting are explained by direct central effects of GLP-1 and delayed gastric emptying gastroesophageal reflux disease Hyperchlorhydria In a nonsurgical population-based cohort that included 25,617 patients, Faillie et al. reported that patients receiving GLP-1RAs had an increased risk of intestinal obstruction compared to SGLT-2 inhibitors (HR 3.48; 95% CI 1.79, 6.79) ( Faillie et al. 2022). Potential Anesthetic Considerations increase the risk of postoperative nausea and vomiting Aspiration

6. Considerations for Anesthesia with GLP-1RA Therapy Patient History and Medication Review Thoroughly document the patient's history, including GLP-1RA use, dosage, and timing of the last administration. Optimizing Glycemic Control Coordinate with the patient's endocrinologist to ensure adequate glycemic control prior to surgery. Consider adjusting medication schedules as needed. Pre-Operative Fasting Guideline (assessment of preoperative risk) GLP-1RAs can prolong gastric emptying. Provide clear fasting guidelines to minimize the risk of aspiration during anesthesia.

7. Glycemic control can influence gastric emptying. While it is usually normal or modestly accelerated with well-controlled DM, inadequate glycemic control may delay gastric emptying. Furthermore, although long-acting GLP-1RAs slow gastric emptying, it is less pronounced than short-acting GLP-1RAs. In addition, the effect on gastric emptying depends on the dose and duration of medication use. Delay in gastric emptying is attenuated with dose escalation and with duration, which suggests possible tachyphylaxis. Delayed emptying occurs within 12 weeks of semaglutide use and then tends to subside or resolve after 20 weeks. Accordingly, adverse GI effects attributed to delayed gastric emptying tend to peak at around 12 weeks, and subsequently subside. l . GLP-1RA-INDUCED DELAYED GASTRIC EMPTYING

8. PREPROCEDURE FASTING INTERVAL FOR PATIENTS ON A GLP-1RA longer fasting times are associated with significant adverse physiological derangement and adverse patient-reported outcomes such as discomfort, anxiety, thirst, hunger, nausea, and omission of medications. Slows Gastric Emptying GLP-1RAs delay gastric emptying and increase RGV even after conventional fasting times

9. Strategies to reduce the risk of peri-procedural retained gastric contents and pulmonary aspiration in patients prescribed glucagon-like peptide-1 (GLP-1) receptor agonists . Medical Decision-Making Liquid diet for one day before procedure Increase fasting duration Withholding GLP-1receptor agonists for three half-lives Use of pro-kinetic drugs,. eg . metoclopramide and/or erythromycin Rapid sequence intubation Active decompression of stomach with nasogastric tube Use of gastrointestinal symptoms as a marker off the risk of retained gastric contents Pre-procedural gastric ultrasound

10. American Society of Anesthesiologists Consensus-Based Guidance on Preoperative GLP-1 Receptor Agonists Management* Assessment Days prior surgery Day of procedure

11. Principles of Gastric Ultrasound Assessment The I-AIM framework for the performance of point-of-care gastric ultrasound Indication Uncertain prandial status Known or suspected delayed gastric emptying Medical management Image analysis Decision-making Interpretation Device selection Patient position Sonographic imaging

12. Techniques and Interpretation of Gastric Ultrasound 1 Transducer Placement Transducer in the sagittal plane in the epigastrium, perpendicular to skin Sweep from left costal margin, heel-to-toe, rotation of the transducer 2 Image Acquisition The RLD position is necessary for an accurate exam because it ensures that all gastric contents, particularly in low-volume states, have shifted toward the gravitationally dependent antrum and are accounted for in the scan 3 Interpretation A qualitative exam, and quantitative (or volume assessment) in some selected cases, is required to interpret a gastric POCUS. The extremes of content (empty or solid) are of obvious clinical significance

13. Sonographic imaging Vertebral bodies Long axis of abdominal aorta Pancreas Liver Short axis of gastric antrum Quantitative assessment CSA in the RLD position Strengths and limitations Pediatric population Technical difficulties Gastric volume (ml)=27+(14.6×RLD-CSA)–(1.28×age [yrs]). Anatomical finding

14. Gastric ultrasound findings based on different types of gastric contents. (A) Target-like appearance of the empty stomach (flat antrum), low risk of aspiration; (B) dilated stomach with liquid contents, volume assessment required; (C) stomach with solid contents and air creating artifact, early phase following eating, high risk of aspiration; (D) dilated stomach with hypoechoic components, later phase following solid or non-clear liquid consumption.

15. Suggested clinical algorithm for gastric ultrasound and aspiration risk assessment. CSA, cross-sectional area; GV: gastric volume; RLD, right lateral decubitus Risk stratification

16. Sherwin M, Hamburger J, Katz D, DeMaria S Jr. Influence of semaglutide use on the presence of residual gastric solids on gastric ultrasound: a prospective observational study in non-obese patients recently started on semaglutide . Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02549-5 Meier JJ. Efficacy of semaglutide in a subcutaneous and an oral formulation. Front Endocrinol (Lausanne) 2021; 12: 645617. https://doi.org/10.3389/fendo.2021.645617 Klein SR, Hobai IA. Semaglutide , delayed gastric emptying, and intraoperative pulmonary aspiration: a case report. Can J Anesth 2023; https://doi.org/10.1007/s12630-023-02440-3 Willson CM, Patel L, Middleton P, Desai M. Glucagon-Like Peptide-1 Agonists and General Anesthesia: Perioperative Considerations and the Utility of Gastric Ultrasound. Cureus . 2024 Apr 11;16(4):e58042. doi : 10.7759/cureus.58042. PMID: 38738030; PMCID: PMC11088359.