1
|
Filipovic MG, Baettig SJ, Ganter MT, Asai T, Luedi MM. Diabetes mellitus and the risk of aspiration - Safe and (ultra)sound? J Clin Anesth 2024; 96:111396. [PMID: 38267325 DOI: 10.1016/j.jclinane.2024.111396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 01/13/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Mark G Filipovic
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Sascha J Baettig
- Institute of Anaesthesiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael T Ganter
- Institute of Anaesthesiology and Critical Care Medicine, Medical Faculty, Klinik Hirslanden Zurich, University of Zurich, Zurich, Switzerland
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University, Koshigaya Hospital, 2-1-50 Minami-Koshigaya, Koshigaya, Saitama 343-8555, Japan
| | - Markus M Luedi
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Anesthesiology, Rescue and Pain Medicine, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
2
|
Klonoff DC, Kim SH, Galindo RJ, Joseph JI, Garrett V, Gombar S, Aaron RE, Tian T, Kerr D. Risks of peri- and postoperative complications with glucagon-like peptide-1 receptor agonists. Diabetes Obes Metab 2024; 26:3128-3136. [PMID: 38742898 DOI: 10.1111/dom.15636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/16/2024]
Abstract
AIM To assess whether adults with diabetes on oral hypoglycaemic agents undergoing general endotracheal anaesthesia during nine common surgical procedures who are glucagon-like peptide-1 receptor agonist (GLP1-RA) users, compared with non-users, are at increased risk of six peri- and post-procedure complications. MATERIALS AND METHODS A retrospective observational cohort analysis of over 130 million deidentified US adults with diabetes (defined as being on oral hypoglycaemic agents) from a nationally representative electronic health dataset between 1 January 2015 and 1 April 2023 was analysed. Cohorts were matched by high-dimensionality propensity scoring. We compared the odds of six peri- and postoperative complications in GLP1-RA users and non-users. A sensitivity analysis compared these odds in GLP1-RA users to non-users with diabetes and obesity. We measured the odds of (a) a composite outcome of postoperative decelerated gastric emptying, including antiemetic use, ileus within 7 days post-procedure, gastroparesis diagnosis, gastric emptying study; (b) postoperative aspiration or pneumonitis; (c) severe respiratory failure; (d) postoperative hypoglycaemia; (e) inpatient mortality; and (f) 30-day mortality. RESULTS Among 13 361 adults with diabetes, 16.5% were treated with a GLP1-RA. In the high-dimensionality propensity score-matched cohort, GLP1-RA users had a lower risk of peri- and postoperative complications for decelerated gastric emptying and antiemetic use compared with non-users. The risk of ileus within 7 days, aspiration/pneumonitis, hypoglycaemia and 30-day mortality were not different. A sensitivity analysis showed similar findings in patients with diabetes and obesity. CONCLUSION No increased risk of peri- and postoperative complications in GLP1-RA users undergoing surgery with general endotracheal anaesthesia was identified.
Collapse
Affiliation(s)
- David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, California, USA
| | - Sun H Kim
- Department of Medicine - Endocrinology, Gerontology, and Metabolism, Stanford University School of Medicine, Stanford, California, USA
| | - Rodolfo J Galindo
- Division of Endocrinology, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Jeffery I Joseph
- Department of Anesthesiology, The Jefferson Artificial Pancreas Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Rachel E Aaron
- Diabetes Technology Society, Burlingame, California, USA
| | - Tiffany Tian
- Diabetes Technology Society, Burlingame, California, USA
| | - David Kerr
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| |
Collapse
|
3
|
Kovoor JG, Rayner CK, Wu T, Jalleh RJ, Maddern GJ, Horowitz M, Jones KL. Effect of lixisenatide on liquid gastric emptying in type 2 diabetes - Implications for the use of GLP-1 receptor agonists before procedures. J Diabetes Complications 2024; 38:108793. [PMID: 38870730 DOI: 10.1016/j.jdiacomp.2024.108793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 06/04/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
Gastric emptying of a glucose drink was measured in people with type 2 diabetes given lixisenatide (20 μg/day or placebo) for 8 weeks. Intragastric retention at 240 min (2 (0-11)% vs 48 (3-97)%; P < 0.0001) was much greater with lixisenatide than placebo. Accordingly, lixisenatide may delay liquid gastric emptying markedly.
Collapse
Affiliation(s)
- Joshua G Kovoor
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia; The University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Christopher K Rayner
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tongzhi Wu
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ryan J Jalleh
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Guy J Maddern
- The University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| |
Collapse
|
4
|
Rüggeberg A, Meybohm P, Nickel EA. Preoperative fasting and the risk of pulmonary aspiration-a narrative review of historical concepts, physiological effects, and new perspectives. BJA OPEN 2024; 10:100282. [PMID: 38741693 PMCID: PMC11089317 DOI: 10.1016/j.bjao.2024.100282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/27/2024] [Indexed: 05/16/2024]
Abstract
In the early days of anaesthesia, the fasting period for liquids was kept short. By the mid-20th century 'nil by mouth after midnight' had become routine as the principles of the management of 'full stomach' emergencies were extended to include elective healthy patients. Back then, no distinction was made between the withholding of liquids and solids. Towards the end of the last century, recommendations of professional anaesthesiology bodies began to reduce the fasting time of clear liquids to 2 h. This reduction in fasting time was based on the understanding that gastric emptying of clear liquids is rapid, exponential, and proportional to the current filling state of the stomach. Furthermore, there was no evidence of a link between drinking clear liquids and the risk of aspiration. Indeed, most instances of aspiration are caused by failure to identify aspiration risk factors and adjust the anaesthetic technique accordingly. In contrast, long periods of liquid withdrawal cause discomfort and may also lead to serious postoperative complications. Despite this, more than two decades after the introduction of the 2 h limit, patients still fast for a median of up to 12 h before anaesthesia, mainly because of organisational issues. Therefore, some hospitals have decided to allow patients to drink clear liquids within 2 h of induction of anaesthesia. Well-designed clinical trials should investigate whether these concepts are safe in patients scheduled for anaesthesia or procedural sedation, focusing on both aspiration risk and complications of prolonged fasting.
Collapse
Affiliation(s)
- Anne Rüggeberg
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Eike A. Nickel
- Department of Anaesthesiology and Pain Therapy, Helios Klinikum Emil von Behring, Berlin, Germany
| |
Collapse
|
5
|
Perlas A, Xiao MZX, Tomlinson G, Jacob B, Abdullah S, Kruisselbrink R, Chan VWS. Baseline Gastric Volume in Fasting Diabetic Patients Is Not Higher than That in Nondiabetic Patients: A Cross-sectional Noninferiority Study. Anesthesiology 2024; 140:648-656. [PMID: 37883294 DOI: 10.1097/aln.0000000000004815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
BACKGROUND The physiology of diabetes mellitus can increase the risk of perioperative aspiration, but there is limited and contradictory evidence on the incidence of "full stomach" in fasting diabetic patients. The aim of this study is to assess the baseline gastric content (using gastric ultrasound) in diabetic and nondiabetic patients scheduled for elective surgery who have followed standard preoperative fasting instructions. METHODS This was a prospective, noninferiority study of 180 patients (84 diabetic and 96 nondiabetic patients). Bedside ultrasound was used for qualitative and quantitative assessment of the gastric antrum in the supine and right lateral decubitus positions. Fasting gastric volume was estimated based on the cross-sectional area of the gastric antrum and a validated model. The hypothesis was that diabetic patients would not have a higher baseline fasting gastric volume compared to nondiabetic patients, with a noninferiority margin of 0.4 ml/kg. Secondary aims included the comparison of the incidence of full stomach (solid content or more than 1.5 mL/kg of clear fluid), estimation of the 95th percentile of the gastric volume distribution in both groups, and examination of the association between gastric volume, glycemic control, and diabetic comorbidities. RESULTS The baseline gastric volume was not higher in diabetic patients (0.81 ± 0.61 ml/kg) compared to nondiabetic patients (0.87 ± 0.53 ml/kg) with a mean difference of -0.07 ml/kg (95% CI, -0.24 to 0.10 ml/kg). A total of 13 (15.5%) diabetic and 11 (11.5%) nondiabetic patients presented more than 1.5 ml/kg of gastric volume (95% CI for difference, -7.1 to 15.2%). There was little correlation between the gastric volume and either the time since diagnosis or HbA1C. CONCLUSIONS The data suggest that the baseline gastric volume in diabetic patients who have followed standard fasting instructions is not higher than that in nondiabetic patients. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Anahi Perlas
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; and Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - George Tomlinson
- Biostatistical Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Binu Jacob
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sara Abdullah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Vincent W S Chan
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Dhatariya K, Levy N, Russon K, Patel A, Frank C, Mustafa O, Newland-Jones P, Rayman G, Tinsley S, Dhesi J. Perioperative use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors for diabetes mellitus. Br J Anaesth 2024; 132:639-643. [PMID: 38290906 DOI: 10.1016/j.bja.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
Type 2 diabetes mellitus is an increasingly common long-term condition, and suboptimal perioperative glycaemic control can lead to postoperative harms. The advent of new antidiabetic drugs, in particular glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors, has enabled perioperative continuation of these medicines, thus avoiding the harms of variable rate i.v. insulin infusions whilst providing glycaemic control. There are differences between medicines regulatory agencies and organisations on how these classes that are most often used to treat diabetes mellitus, (but also in the case of SGLT2 inhibitors chronic kidney disease and heart failure in those without diabetes) should be managed in the perioperative period. In this commentary, we argue that GLP-1 receptor agonists should continue during the perioperative period and that SGLT2 inhibitors should only be omitted the day prior to a planned procedure . The reasons for the differing advice advocated between regulatory agencies and what anaesthetic practitioners should do in the face of continuing uncertainty are discussed.
Collapse
Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK; Norwich Medical School, University of East Anglia, Norwich, UK.
| | - Nicholas Levy
- Department of Anaesthetics, West Suffolk Hospital, Bury St Edmonds, Suffolk, UK
| | - Kim Russon
- Department of Anaesthetics, The Rotherham NHS Foundation Trust Hospital, Rotherham, UK
| | - Anil Patel
- Department of Anaesthetics, The Royal National ENT & Eastman Dental Hospitals, University College London Hospitals, London, UK
| | - Claire Frank
- Pharmacy Department, Betsi Cadwaladr University Health Board, Wrexham, UK
| | - Omar Mustafa
- Department of Diabetes, King's College Hospital, London, UK; King's College, London, UK
| | - Philip Newland-Jones
- Department of Diabetes & Endocrinology, Southampton General Hospital, Southampton, UK
| | - Gerry Rayman
- Ipswich Diabetes Centre, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Sarah Tinsley
- Pharmacy, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Jugdeep Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
7
|
Huang S, Cao S, Sun X, Zhang J. Gastric point-of-care ultrasonography in patients undergoing radical gastrointestinal surgery before anesthetic induction: an observational cohort study. BMC Anesthesiol 2024; 24:90. [PMID: 38433227 PMCID: PMC10910806 DOI: 10.1186/s12871-024-02473-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 02/26/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Pulmonary aspiration of gastric contents is a serious perioperative complication. Patients with gastric cancer may experience delayed gastric emptying. However, the role of qualitative and quantitative gastric ultrasound assessments in this patient population before anesthesia induction has not yet been determined. METHODS Adult patients with gastrointestinal cancer were recruited and examined using gastric point-of-care ultrasound (POCUS) before anesthetic induction from March 2023 to August 2023 in a tertiary cancer center. Three hundred patients with gastric cancer were conducted with POCUS prior to induction, and three hundred patients with colorectal cancer were included as controls. The cross-sectional area (CSA) of the gastric antrum and gastric volumes (GV) were measured and calculated. We determined the nature of the gastric contents and classified the antrum using a 3-point grading system. A ratio of GV to body weight > 1.5mL/Kg was defined as a high risk of aspiration. RESULTS In patients with gastric cancer, 70 patients were classified as grade 2 (23%, including 6 patients with solid gastric contents) and 63 patients (21%) were identified as having a high risk of aspiration. Whereas in patients with colorectal cancer, only 11 patients were classified as grade 2 (3.7%), and 27 patients (9.7%) were identified as having a high risk of aspiration. A larger tumor size (OR:1.169, 95% CI 1.045-1.307, P = 0.006), tumor located in antrum (OR:2.304, 95% CI 1.169-4.539,P = 0.016), gastrointestinal obstruction (OR:21.633, 95% CI 4.199-111.443, P < 0.0001) and more lymph node metastasis (OR:2.261, 95% CI 1.062-4.812, P = 0.034) were found to be positively while tumor site at cardia (OR:0.096, 95% CI 0.019-0.464, P = 0.004) was negatively associated with high aspiration risk in patients with gastric cancer. CONCLUSION The Gastric POCUS prior to induction provides an assessment of the status of gastric emptying and can identify the patients at high risk of aspiration, especially those with gastric cancer. TRIAL REGISTRATION Chinese Clinical Trial Registry ( www.chictr.org.cn ) identifier: ChiCTR2300069242; registered 10 March 2023.
Collapse
Affiliation(s)
- Siming Huang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No.270, DongAn Road, Xuhui District, Shanghai, 200032, China
| | - Shumei Cao
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No.270, DongAn Road, Xuhui District, Shanghai, 200032, China
| | - Xia Sun
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No.270, DongAn Road, Xuhui District, Shanghai, 200032, China
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No.270, DongAn Road, Xuhui District, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, No.270, DongAn Road, Xuhui District, Shanghai, 200032, China.
| |
Collapse
|
8
|
Sbaraglia F, Cuomo C, Della Sala F, Festa R, Garra R, Maiellare F, Micci DM, Posa D, Pizzo CM, Pusateri A, Spano MM, Lucente M, Rossi M. State of the Art in Pediatric Anesthesia: A Narrative Review about the Use of Preoperative Time. J Pers Med 2024; 14:182. [PMID: 38392615 PMCID: PMC10890671 DOI: 10.3390/jpm14020182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
This review delves into the challenge of pediatric anesthesia, underscoring the necessity for tailored perioperative approaches due to children's distinctive anatomical and physiological characteristics. Because of the vulnerability of pediatric patients to critical incidents during anesthesia, provider skills are of primary importance. Yet, almost equal importance must be granted to the adoption of a careful preanesthetic mindset toward patients and their families that recognizes the interwoven relationship between children and parents. In this paper, the preoperative evaluation process is thoroughly examined, from the first interaction with the child to the operating day. This evaluation process includes a detailed exploration of the medical history of the patient, physical examination, optimization of preoperative therapy, and adherence to updated fasting management guidelines. This process extends to considering pharmacological or drug-free premedication, focusing on the importance of preanesthesia re-evaluation. Structural resources play a critical role in pediatric anesthesia; components of this role include emphasizing the creation of child-friendly environments and ensuring appropriate support facilities. The results of this paper support the need for standardized protocols and guidelines and encourage the centralization of practices to enhance clinical efficacy.
Collapse
Affiliation(s)
- Fabio Sbaraglia
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Christian Cuomo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Filomena Della Sala
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rossano Festa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Rossella Garra
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Federica Maiellare
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Daniela Maria Micci
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Posa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Cecilia Maria Pizzo
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Angela Pusateri
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michelangelo Mario Spano
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Monica Lucente
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marco Rossi
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
9
|
Yan Y, Jin Y, Cao Y, Chen C, Zhao X, Xia H, Yan L, Si Y, Zou J. Development and validation of a novel nomogram model to assess the risk of gastric contents in outpatients undergoing elective sedative gastrointestinal endoscopy procedures. Clin Res Hepatol Gastroenterol 2024; 48:102277. [PMID: 38159677 DOI: 10.1016/j.clinre.2023.102277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/24/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Gastric contents may contribute to patients' aspiration during anesthesia. Ultrasound can accurately assess the risk of gastric contents in patients undergoing sedative gastrointestinal endoscopy (GIE) procedures, but its efficiency is limited. Therefore, developing an accurate and efficient model to predict gastric contents in outpatients undergoing elective sedative GIE procedures is greatly desirable. METHODS This study retrospectively analyzed 1501 patients undergoing sedative GIE procedures. Gastric contents were observed under direct gastroscopic vision and suctioned through the endoscope. High-risk gastric contents were defined as having solid content or liquid volume > 25 ml and pH < 2.5; otherwise, they were considered low-risk gastric contents. Univariate analysis and multivariate analysis were used to select the independent risk factors to predict high-risk gastric contents. Based on the selected independent risk factors, we assigned values to each independent risk factor and established a novel nomogram. The performance of the nomogram was verified in the testing cohort by the metrics of discrimination, calibration, and clinical usefulness. In addition, an online accessible web calculator was constructed. RESULTS We found BMI, cerebral infarction, cirrhosis, male, age, diabetes, and gastroesophageal reflux disease were risk factors for gastric contents. The AUROCs were 0.911 and 0.864 in the development and testing cohort, respectively. Moreover, the nomogram showed good calibration ability. Decision curve analysis and Clinical impact curve demonstrated that the predictive nomogram was clinically useful. The website of the nomogram was https://medication.shinyapps.io/dynnomapp/. CONCLUSIONS This study demonstrates that clinical variables can be combined with algorithmic techniques to predict gastric contents in outpatients. Nomogram was constructed from routine variables, and the web calculator had excellent clinical applicability to assess the risk of gastric contents accurately and efficiently in outpatients, assist anesthesiologists in assessment and identify the most appropriate patients for ultrasound.
Collapse
Affiliation(s)
- Yuqing Yan
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yuzhan Jin
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yuanyuan Cao
- Department of Anesthesiology, Perioperative and Pain Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiuxiu Zhao
- Department of Anesthesiology, Perioperative and Pain Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Huaming Xia
- Nanjing Xiaheng Network System Co., Ltd., Nanjing, China
| | - Libo Yan
- Jiangsu Kaiyuan Pharmaceutical Co., Ltd., Nanjing, China
| | - Yanna Si
- Department of Anesthesiology, Perioperative and Pain Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China; Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China.
| |
Collapse
|
10
|
Flore G, Deledda A, Fosci M, Lombardo M, Moroni E, Pintus S, Velluzzi F, Fantola G. Perioperative Nutritional Management in Enhanced Recovery after Bariatric Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6899. [PMID: 37835169 PMCID: PMC10573058 DOI: 10.3390/ijerph20196899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/15/2023]
Abstract
Obesity is a crucial health problem because it leads to several chronic diseases with an increased risk of mortality and it is very hard to reverse with conventional treatment including changes in lifestyle and pharmacotherapy. Bariatric surgery (BS), comprising a range of various surgical procedures that modify the digestive tract favouring weight loss, is considered the most effective medical intervention to counteract severe obesity, especially in the presence of metabolic comorbidities. The Enhanced Recovery After Bariatric Surgery (ERABS) protocols include a set of recommendations that can be applied before and after BS. The primary aim of ERABS protocols is to facilitate and expedite the recovery process while enhancing the overall effectiveness of bariatric procedures. ERABS protocols include indications about preoperative fasting as well as on how to feed the patient on the day of the intervention, and how to nourish and hydrate in the days after BS. This narrative review examines the application, the feasibility and the efficacy of ERABS protocols applied to the field of nutrition. We found that ERABS protocols, in particular not fasting the patient before the surgery, are often not correctly applied for reasons that are not evidence-based. Furthermore, we identified some gaps in the research about some practises that could be implemented in the presence of additional evidence.
Collapse
Affiliation(s)
- Giovanna Flore
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Andrea Deledda
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Michele Fosci
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Mauro Lombardo
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, Via di Val Cannuta, 247, 00166 Rome, Italy;
| | - Enrico Moroni
- Obesity Surgery Unit, Department of Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione G. Brotzu, 09134 Cagliari, Italy; (E.M.); (S.P.); (G.F.)
| | - Stefano Pintus
- Obesity Surgery Unit, Department of Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione G. Brotzu, 09134 Cagliari, Italy; (E.M.); (S.P.); (G.F.)
| | - Fernanda Velluzzi
- Obesity Unit, Department of Medical Sciences and Public Health, University of Cagliari, 09124 Cagliari, Italy; (G.F.); (A.D.); (M.F.)
| | - Giovanni Fantola
- Obesity Surgery Unit, Department of Surgery, Azienda di Rilievo Nazionale ed Alta Specializzazione G. Brotzu, 09134 Cagliari, Italy; (E.M.); (S.P.); (G.F.)
| |
Collapse
|
11
|
Rong H, Dai W, Qin Y, Meng Z, Zou X, Wang B, Wei Q, Xie Y. Ultrasonographic Assessment of Gastric Volume in Fasted Patients Undergoing Gastrointestinal Endoscopy Under Sedation. Ther Clin Risk Manag 2023; 19:685-698. [PMID: 37641782 PMCID: PMC10460589 DOI: 10.2147/tcrm.s424890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/13/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose In this prospective observational study, an ultrasonographic measurement of antral cross-sectional area (ACSA) was conducted to evaluate the gastric content and volume as well as to identify high-risk stomach in non-pregnant adult surgical patients adhering to preanesthetic fasting guidelines. Patients and Methods Fasted patients undergoing gastrointestinal endoscopy under sedation were included. Ultrasonographic measurements of ACSA were conducted in both semi-recumbent and right lateral decubitus positions before endoscopic procedures. Gastroscopy was employed to guide the measurement of suctioned gastric volume (GV). Ultrasonography was performed to assess gastric contents and identify patients with high-risk stomach. The relationship between ACSA and suctioned GV was also evaluated. Results ACSA was evaluated in 736 out of 782 patients. A significant positive correlation was discovered between ACSA in the right lateral decubitus position and suctioned GV, which was more reliable than in the semi-recumbent position. To analyze high-risk stomach with a GV > 100 mL, the cutoff value of ACSA in the right lateral decubitus was found to be 7.5 cm2, with the AUC, sensitivity and specificity of 0.80 (95% CI, 0.76-0.82; P<0.001), 82.4% and 67.3%, respectively. A novel mathematical model based on ACSA to estimate GV in non-pregnant fasted adults was presented. Conclusion Ultrasonographic measurement of ACSA can assist anesthesiologists in estimating the risk of pulmonary aspiration of gastric contents during general anesthesia and sedation.
Collapse
Affiliation(s)
- Heng Rong
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Weixin Dai
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yinying Qin
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Zhikeng Meng
- Department of Anesthesiology, The First People’s Hospital of Yulin, Yulin, People’s Republic of China
| | - Xia Zou
- Department of Anesthesiology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, People’s Republic of China
| | - Binbin Wang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Qiufeng Wei
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
- Guangxi Key Laboratory of Enhanced Recovery After Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| |
Collapse
|
12
|
Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 2023:S0007-0912(23)00128-9. [PMID: 37061429 PMCID: PMC10375498 DOI: 10.1016/j.bja.2023.02.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023] Open
Abstract
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
Collapse
Affiliation(s)
- Kieran Crowley
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Pádraig Ó Scanaill
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
13
|
Jia H, He E, Gao S, Hao W, Li Y, Liu W, Chen X, Jia Y, Wang Y. Ultrasound assessment of gastric contents and volume in patients undergoing endoscopic endonasal transsphenoidal surgery: a prospective observational study. Sci Rep 2023; 13:2848. [PMID: 36801927 PMCID: PMC9938176 DOI: 10.1038/s41598-023-29893-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Intraoperative ingestion of blood, cerebrospinal fluid, and irrigation fluid can lead to an increase in gastric volume, resulting in the potential risk of aspiration in patients after endoscopic endonasal transsphenoidal surgery (EETS). In this prospective observational study, we aimed to assess the volume of gastric contents in patients undergoing this neurosurgical procedure using ultrasound, and to determine the factors associated with volume change. Eighty-two patients diagnosed with pituitary adenoma were recruited consecutively. Semi-quantitative (Perlas scores: 0, 1 and 2) and quantitative (cross-sectional area, CSA) ultrasound assessments of the gastric antrum were performed immediately before and after surgery in the semi-recumbent and semi-recumbent right-lateral positions. Seven (8.5%) patients had antrum scores from preoperative grade 0 to postoperative grade 2; nine (11%) patients had antrum scores from preoperative grade 0 to postoperative grade 1. The mean ± standard deviation (SD) of increased gastric volume was 71.0 ± 33.1 mL and 236.5 ± 32.4 mL in postoperative grade 1 and 2 groups, respectively. Subgroup analysis showed that 11 (13.4%) patients (4 in grade 1 and all in grade 2) had postoperative estimated gastric volume > 1.5 mL kg-1 (mean ± SD 3.08 ± 1.67, range 1.51-5.01 mL kg-1). Logistic regression analysis revealed that older age, diabetes mellitus, and long surgical duration were independent risk factors for significant volume change (all P < 0.05). Our results showed a significant increase in gastric volume in some patients who underwent EETS. Bedside ultrasound measurements of gastric volume can be used to assess the postoperative aspiration risk, particularly in older diabetic patients with a longer surgical duration.
Collapse
Affiliation(s)
- Haitao Jia
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Ertao He
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Shixiong Gao
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Wei Hao
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yanli Li
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Wei Liu
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Xiaoxia Chen
- grid.411294.b0000 0004 1798 9345Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030 Gansu China
| | - Yanfei Jia
- grid.411294.b0000 0004 1798 9345Department of Neurosurgery, Lanzhou University Second Hospital, Lanzhou, 730030 Gansu China
| | - Yingbin Wang
- Department of Anesthesiology and Postanesthesia Care Unit, Lanzhou University Second Hospital, Chengguan District, Lanzhou, 730030, Gansu, China.
| |
Collapse
|
14
|
Bouvet L, Chassard D, Desgranges FP. Risk of pulmonary aspiration of gastric contents in patients with diabetes mellitus. Comment on Br J Anaesth 2021, 217: 224-235. Br J Anaesth 2021; 128:e19-e20. [PMID: 34749992 DOI: 10.1016/j.bja.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Lionel Bouvet
- Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France.
| | | | | |
Collapse
|
15
|
Xiao MZX, Englesakis M, Perlas A. Gastric content and perioperative pulmonary aspiration in patients with diabetes mellitus: a scoping review. Br J Anaesth 2021; 127:224-235. [PMID: 34023055 DOI: 10.1016/j.bja.2021.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Gastric emptying may be delayed in patients with diabetes mellitus (DM). However, the incidence of full stomach in fasting patients with DM and their risk of pulmonary aspiration under anaesthesia is not well understood. METHODS A scoping review was undertaken to map the literature on aspiration risk in DM. A search was conducted in seven bibliographic databases, including MEDLINE and Embase, for original articles that studied aspiration risk, gastric emptying, or gastric content and volume. Selection and characterisation were performed by two independent reviewers using a predefined protocol registered externally. RESULTS The search identified 5063 unique records, and 16 studies (totalling 775 patients with DM) were selected: nine studied gastric emptying and seven studied gastric content or volume. There were no studies reporting the incidence of aspiration in subjects with DM. All nine studies reported delayed emptying in patients with DM compared with healthy controls. Amongst the seven studies that compared gastric residual content/volume (GRV) in the perioperative period, five reported clinically negligible GRV in both patients with DM and controls, whereas two observed a higher incidence of 'full' stomach in patients with DM. CONCLUSIONS The evidence concerning the aspiration risk for surgical patients with DM is based on a limited number of studies, mostly unblinded, reporting physiological data on gastric emptying and gastric volume as surrogate markers of aspiration risk. Data on fasting gastric content and volume in patients with DM are limited and contradictory; hence, the true risk of aspiration in fasting patients with DM is unknown.
Collapse
Affiliation(s)
- Maggie Z X Xiao
- Medicine, Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Anahi Perlas
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, ON, Canada.
| |
Collapse
|