P085: CORRELATING GASTRIC ULTRASOUND WITH ENDOSCOPY FOR A DIABETIC PATIENT ON A GLP-1 RA
Brett A Toimil, MD1; Sofia I Cartaya, MD2; Leshawn D Richards, MD1
1Moffitt Cancer Center, Department of Anesthesiology; 2University of South Florida Morsani College of Medicine
Introduction/Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are increasingly used in the management of diabetes and obesity. One of the potential risks associated with their use is delayed gastric emptying, which can affect perioperative management and increase the risk of aspiration during surgery. The 2024 American Society of Anesthesiologists (ASA) guidance is to hold weekly dosed GLP-1 RAs for one week prior to planned anesthetics. Similarly, the ASA published guidance in 2023 for management of patients on GLP-1 RAs on the day of their procedure. If there are GI symptoms like nausea, vomiting, retching, abdominal bloating, or abdominal pain, the recommendation is to consider delaying elective procedures. If the GLP-1 RA was not held prior to presentation and no GI symptoms are present, the recommendation is to consider gastric ultrasound if available or engaging in a shared-decision making model with the patient to consider proceeding with full-stomach precautions or delaying.
Methods/Case Presentation: Here we present the case of an 80-year-old male with choledocholithiasis and a medical history significant for insulin-dependent diabetes of 30 years who presented for esophagogastroduodenoscopy. He had an absence of GI symptoms and had adhered to a two-week semaglutide hold preoperatively. A rapid sequence induction and atraumatic glidescope intubation was performed and an endotracheal tube was placed without noting gastric contents in the oropharynx or hypopharynx. Upon advancement of the endoscope into the gastric body, a large amount of residual solid food was noted and the procedure was therefore aborted (Fig. 1). Prior to extubation, gastric ultrasound was performed by a certified ultrasonographer re-demonstrating the presence of gastric contents (Fig. 2).
Figure 1: Residual food bolus imaged in the gastric body directly visualized.
Figure 2: Ultrasound representation of food bolus in gastric body.
Results: The patient was extubated uneventfully after regaining spontaneous ventilation. The patient was then instructed to hold semaglutide for 3 weeks and maintain a 24-hour liquid diet for a later attempt at the procedure, and underwent a successful endoscopic retrograde cholangiopancreatography two months later following these instructions.
Discussion/Conclusion: It is likely that use of GLP-1 agonists will continue to increase in the coming years. Despite this, the ideal window for preoperative cessation of these medications to reduce the risk of aspiration has not been well-established. Multi-society guidance regarding perioperative care for patients on glucagon-like peptide-1 receptor agonists currently focuses on medication hold times and presence of GI symptoms on the day of the procedure. This case illustrates how gastric ultrasound may be beneficial for identifying aspiration risk for certain patient populations who follow this guidance, but may still have a full stomach in the absence of GI symptoms on the day of the procedure.