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GLP Agonists with Peter Arrabal · Style Points

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Hello anesthesia enthusiasts and welcome to another episode of Style Points. Today we're
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going to be talking to Dr. Peter Aribal about GLP agonists and their anesthetic management.
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However, before we get to Dr. Aribal, I'm introducing a new segment to the show which
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I'm calling the RSI. The RSI of course stands for resident selected information. Essentially
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it's going to be a short segment at the beginning of the podcast where an educational topic
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is presented in just a few minutes. Here today for that segment is Nate Moore. Before becoming
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one of our chief residents, Nate toiled away for two years in an internal medicine residency
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before he finally saw the light and switched to anesthesiology. He's a co-producer of
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the show and a good friend of mine. Nate, welcome to the show.
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Thank you. I'm glad to be here. What resident selected information do you have for us today?
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I'm here to talk to you about the TAG. Imagine this scenario. You're in the OR and you've
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never seen so much blood before. You wish you remembered your shoe covers today. Worse,
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blood bank just called you. There's a shortage of every blood product in the city. You need
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a test that tells you what blood products your patient needs and fast. What will you
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do? The TAG or thromboelastogram is a test that accurately measures a patient's clotting
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function and directs you toward what kind of blood products you need to give them. It
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also provides results in real time, often more quickly than traditional clotting tests.
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Studies have shown that using the TAG to guide resuscitation can help safely reduce the amount
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of blood product given in certain patient populations, making it a valuable tool to
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help reduce the incidence of transfusion complications and preserve our limited blood supply. One
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thing that helped me understand how the TAG works is understanding how the TAG graph is
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actually generated by the TAG machine. If you don't have a picture of a TAG in front
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of you, think about a wine glass lying on its side. Imagine the thin stem of the wine
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glass is on the left and the bulbous cup part of the glass that actually holds the wine
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is on the right with the edges that touch your lips gently tapering in from left to
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right. The way a TAG machine works is this. A small sample of the patient's blood is
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placed in a small cup in the machine and a pin suspended by a thin wire is dipped into
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the center of the sample of blood. The machine then rotates the cup back and forth with the
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pin in the center of the sample. Initially the pin doesn't move at all, the blood is
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liquid, it just sloshes around the pin and the pin stays still. But with time the blood
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begins to form a clot between the pin and the walls of the cup and the pin eventually
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has to move as the clot forces the pin to twist back and forth along with the cup. As
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the clot gets stronger and stronger, the pin has to twist more and more, approaching the
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same amount of rotation that the cup itself is doing. When we talk about the amplitude
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in a TAG test, we're talking about that rotation. The more rotation the pin has to do, the higher
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amplitude shows up on the TAG graph. Eventually the clot begins to break down and the pin
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rotates less and less as the blood returns to a liquid. Given enough time, the clot dissolves
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entirely and the pin is motionless. During that whole process there are five values that
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a TAG generates. There are the R time, the K time, the alpha angle, the maximum amplitude,
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and the LY 30. And we'll talk about each of those values. The R time is first and that
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measures the time it takes before the coagulation cascade is activated and clot formation begins.
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This is at the start of the process so the pin is sitting in the blood, not moving, since
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there's no movement. That corresponds to the stem of the Y angle S, just a flat line. The
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normal R time is five to ten minutes and a prolonged R time suggests a deficiency in
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clotting factors. The treatment is to give fresh frozen plasma or FFP, which contains
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all of the coagulation factors. Next is the K time or kinetic time. This measures the
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time between initial clot formation, which is the end of the R time, and the point where
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the clot reaches an amplitude of 20 millimeters. You can think of this as measuring the initial
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speed of clot formation. At this point the pin sitting in the patient's blood is just
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starting to move. The coagulation cascade has started and the clot is beginning to adhere
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between the pin and the walls of the cup. Since the pin is rotating, the cup shape of
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the line glass on the TIG graph is beginning to form. But at this point the clot is more
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of a viscous slurry than a firm clot, so only the bottom of the line glass is formed so
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far. A normal K time is one to three minutes and a prolonged K time suggests the patient
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is low on fibrinogen. The treatment is usually to give cryoprecipitate, which contains fibrinogen.
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The alpha angle is really another way of measuring the initial speed of clot formation and it's
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largely used the same way as the K time. It's measured by drawing a line from the end of
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the R time to the point representing the K time and taking the angle of that line. A
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normal angle is 45 to 75 degrees. A decreased alpha angle is interpreted just like a prolonged
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K time, suggesting a lack of fibrinogen, for which the treatment is usually cryoprecipitate.
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The MA, or maximum amplitude, is the point at which the clot is at its strongest, reflecting
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maximal interaction between platelets and fibrin, forcing the pin to rotate the greatest
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amount as the cup rotates around it. At the MA, the cup of the line glass is at the widest
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point on the graph. A normal MA is about 50 to 75 millimeters. A decreased MA usually
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means a patient's platelet count or platelet function is decreased and the treatment is
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usually to transfuse more platelets. The use of DDAVP or desmopressant can also be considered
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to improve platelet function. The final value is the LY30, or lysis of 30 minutes value.
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This is the percentage by which the clot amplitude is decreased from the maximum amplitude after
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30 minutes have passed, which is a measure of fibrinolysis. A normal LY30 is 0 to 10
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percent. An increased LY30 means that an abnormally high amount of fibrinolysis and clot breakdown
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is occurring, and this is often associated with trauma patients, creating the so-called
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death diamond shape. The treatment is to give an antifibrinolytic medication, usually tranexamic
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acid, also known as TXA, or aminocaparic acid. Please remember that the normal ranges I gave
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you for each value are the textbook ranges. The actual normal ranges the lab uses at your
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institution may be different, and you should use those. Now go forth and resuscitate responsibly.
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All right, great job. Thank you so much, Nate. Now on to our guest. I'm here with Dr. Peter
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Erebal. Dr. Erebal was very briefly a resident of mine when I first started as an attending.
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Since then, he went to private practice for a couple of years, then returned to academic
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medicine where he has quickly distinguished himself in both obstetric anesthesia and perioperative
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medicine. He's currently the director of our Center for Perioperative Care, also known
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as our CPC clinic. Dr. Erebal has spent a significant amount of time and effort familiarizing
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himself with the literature surrounding GLP-1 agonists and their perioperative implications.
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As one of our POCUS certified physicians, he also serves on the Flex service where he
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performs gastric ultrasound. All these things make him the perfect person to talk about
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our subject today, GLP-1 agonists and their perioperative implications. Peter, thanks
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for joining us. Thanks for having me. So to start, I'd like to ask you one of my standard
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get to know you questions. If you could invite anyone in the world over for dinner, including
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somebody from the past or even from fiction, who would you invite? Boy, I really hate this
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question. I've gotten this question in job interviews before and it really, really something
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that I really have struggled with in the past. The answer that I usually give to this is
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the person that I named for who was Saint Peter, who was a biblical character, one of
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the early followers of Jesus, and he was the first Pope, the first person to lead the Catholic
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church. I was raised a Catholic. You don't have to be a Catholic to understand most of
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it. I would really love to have the opportunity to sit and have dinner with him because he's
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this historically this incredible leader, this person who really took those formative
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years of the church and created it into the behemoth that it became. But when you look
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back through the descriptions of him in the Bible, he's kind of a goofball. So everybody
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knows the story of Jesus walking on water. And when you see this, when you read the story
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of Jesus walking on water, what happens immediately after they see Jesus walking on water? Peter
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jumps out of the boat and just starts trying to walk on water himself. So he just does
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this incredibly impulsive and out of and completely out of character thing for most other biblical
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characters. Other stories that involve him in the Bible and things where like around
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the execution of Jesus, he just hops up and cuts this dude's ear off. Like totally impulsive
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and totally out of character. So you have this person who's kind of an impulsive goofball
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who ends up being this incredible leader, this incredible person and this foundation
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of the church. And so I would really love to sit and have a conversation with him about
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how you take those, this incredible character that you have, these strong feelings that
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you have and how do you translate that into the ability to lead people, to influence people
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and to really create something on your own. Do you feel like you are also an impulsive
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goofball? I'm not going to answer that question for my own personal protection. Okay. But
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yeah, some people would probably describe me as as impulsive and hopefully not too much
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of a goofball. I've never jumped out of the boat. Okay, well that's fair. So steering
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back towards medicine, what drew you towards your role in the perioperative space? I really
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think that the future of anesthesiology is in the perioperative space. With enough training
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and education, most people with reasonable critical thinking skills can become anesthetists,
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can provide an anesthetic to a patient on any given day. Where we really provide value
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is in the total evaluation, preparation, investigation, optimization, delivery of care and delivery
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of post-op care. So I think that the present and the future of anesthesiology is in the
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perioperative space. I think that we undersell our ability to prepare patients for surgery
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and that we have a lot of value that we can add to most health systems in preventing bad
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things from happening afterwards, shortening hospitalizations, improving patient satisfaction,
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provider satisfaction, surgeon satisfaction by really preparing people in advance in order
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to get them ready to go for surgery so that they can have a good outcome. Okay, so let's
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start by getting a brief overview of what a GLP-1 is. It's something that we've heard
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a lot about in the press. What is it? So GLP-1 receptor agonists, GLP-1 RAs, are a class
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of medication that have been around since about 2005. The first version of this medication
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that was brought to market was called Exenitide, or BiETA is the brand name for it. It was
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ultimately discovered from secretions from the glands of the Gila monster, which is a
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unusual lizard that is found in the Southwest United States. They eat about three to four
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meals in a year and otherwise do not need to consume anything throughout an entire year.
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They are well known among people that live in the Southwest for being highly venomous.
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They're rumored to be fatally venomous, but there are no real case reports of that. The
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bite is reportedly incredibly painful, like hot lava flowing up your arm if you get bit
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by this. They are not an endangered species, but they're a protected species. You can't
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have them as pets. Some people that have been bit by them have had them as pets. So I would
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not recommend having a Gila monster as a pet. I'll check that off my list. But this peptide
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was isolated from their oral secretions and has been studied to be a gastric inhibitory
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protein that helps to decrease gastric emptying, increase insulin secretion, and has been
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utilized as a treatment for diabetes since the mid-2000s. So it's been coming up on 20
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years now that Bayette has been on the market. Over the years, they have discovered more
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and more of these types of medications. More recently, things like Doolaglutide, Semaglutide,
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Drzeppetide, and I'm probably mispronouncing these things so I've always gotten generic
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names wrong. But these are more commonly known as Trulicity, Ozempic, Wegovi, Mongero, and
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most recently, ZeppBound is the newest name for Drzeppetide. Two of these medications
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that are the most commonly used now and that we see the most in the press about are the
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ones that are approved for weight loss, which are the Wegovi and the ZeppBound, which again
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are the weight loss formulations of the Semaglutide and Drzeppetide. Those are the only two that
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have FDA indications for weight loss, and they have an entire titration protocol that
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people go through when they want to utilize these medications for weight loss specifically.
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These are also all medications that are used for treatment of type 2 diabetes, which is
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what they were initially found for. And then as they studied the use of these, they found
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that people did tend to not only have significant decreases in their A1Cs, but also have significant
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weight loss that occurred during their usage of these medications.
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Well, a lot of people want to lose weight. I could certainly use to lose a few pounds.
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So given that, should I just go on one of these GLP-1 agonists to lose 20 pounds?
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The FDA indications for these are that if you are obese with a BMI over 30, or if you
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have a BMI over 27 with multiple health problems, very similar to what the qualifications for
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gastric bypass surgery are. So people that are under a BMI of 30 should not be started
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on these medications as a labeled use. People that are BMI 27 to 30, but that have diabetes,
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heart failure, or other types of medical problems where they would potentially get improvement
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in those other medical problems by losing weight could potentially qualify to receive
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these medications. There are also some problems with insurance coverage for these because
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they are very expensive. So that's another consideration to have in terms of whether
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you want to just immediately start losing weight with this. And then there's also some
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other implications in terms of your other medical problems that you may have that would
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limit your ability to take that.
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I see. What about side effect profile? What can you expect with general side effects for
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somebody on these medications?
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Most of the side effects are reasonably well tolerated. I think the most common things
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that you see when you talk to patients that take these medications are most severe in
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the first few weeks of taking them. Things like nausea and vomiting, constipation. The
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burping really seems to be very, very limiting and upsetting to people. When you talk to
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people that have used these medications for long periods of time, those side effects tend
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to tend to wane as time goes on. That doesn't mean that it will for everybody, but that
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is a common report. A lot of those side effects, especially the belching and the constipation
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are really well treated by continuing to eat. And it sounds very, this doesn't sound very
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intuitive because you're taking these medications and one of the primary effects of them is
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that they decrease your gastric emptying. So food moves slower out of your stomach. It
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makes you less hungry and want to eat less. Where people really struggle with these when
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you read testimonials from people that have used these medications is that they don't
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want to eat at all. And then they end up in a state of starvation ketosis. They end up
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with these sulfury burps where there's absolutely nothing going through their stomach. They
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end up not losing weight because they are in a period of starvation and their metabolic
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rate drops and they can't actually burn any fat because they're simply shutting down.
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So some people have found success by continuing to eat or increasing the amount of calories
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that they take in, in order to get their metabolism back up. The constipation, that's just good
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old fashioned American diet, low fiber diet, where you're already in a relatively low fiber
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state. The only thing that's going to really get those bowels moving is to really get some
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good, you know, have a good balanced diet. When I've talked to patients that are taking
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these medications, the big things that they complain about, like I said, the nausea, vomiting,
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constipation, very rarely diarrhea, but it can exist. You do have to maintain a, if you're
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using these medications strictly for weight loss, you do have to maintain a desire and
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a plan to lose weight. I distinctly remember talking to a patient who had been on Ozempic
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at a weight loss dose for about four years, had been prescribed this for diabetes. Her
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A1C was now in a nice normal range, had been, she was very happy with it, but she hadn't
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lost any weight, had never even considered the possibility that she would lose weight
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with this. Didn't know that it was a medication used for weight loss. So there is still an
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element of needing to intentionally diet, intentionally exercise, increase your metabolic
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rate, increase your overall activity in order to utilize those calories that you are taking
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in. There are some other rare side effects that I think we definitely should talk about
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and consider things like pancreatitis, gallstones, things like that, that are for sure people
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need to consider before they start these medications. And then the black box label is about MEN
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or multiple endocrine neoplasia, thyroid cancers and things like that. Those are based off
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of some rat studies that have not really, not been well studied in humans.
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Okay, so let's zoom in a little bit to our field, anesthesiology. How do these interact
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with and affect our anesthetic plans?
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Directly with the anesthetic plans, you don't see a whole lot of direct interaction there.
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These are not purely hypoglycemic medications in which, similar to sulfonylureas or some
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of those other medications where if they take them or in the perioperative space, they may
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end up unexpectedly hypoglycemic. The big thing that we're worried about with these
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medications is that delayed gastric emptying. One of our most feared complications in anesthesia
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is regurgitation and aspiration of gastric contents. So we get you up to sleep, you're
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awake, you relax your muscles, your stomach is full, the food comes up through your esophagus
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and it goes down your trachea, you end up with an aspiration pneumonia or an aspiration
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pneumonitis. Both of those are very bad. You don't want them, I don't want them, nobody
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should want them. So this is typically why we have these recommendations for people to
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be without any food in their stomach, to be NPO so they can't have anything to eat or
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drink for a certain period before surgery. When you're taking these medications and you
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have delayed gastric emptying, you may have unexpected contents in your stomach that shouldn't
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be there. So you may have followed all the guidelines. You didn't eat anything for eight
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hours beforehand, you didn't drink anything for eight hours beforehand, you show up on
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the day of surgery and your stomach is full. So a result of the intended function of these
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medications is to slow down the exit, the transit of food through the GI system. And
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there are a number of case reports in the literature, there's a number of things in
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the media of people who followed NPO guidelines and still ended up with regurgitation and
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aspiration or had full stomachs when they did endoscopy and looked down in the stomach
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to see what was there. So we've been very concerned about that particular point and
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how this plays into our overall risk mitigation that we can do in the periorbital space for
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patients.
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Okay. So given those risks, what can we do to mitigate them?
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We really don't know. I don't have a very good answer for that. There are guidelines
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from the American Society of Anesthesiologists and there are some guidelines from the GI
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Society as to what you're supposed to do with these medications. We've looked through all
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of these and I've got files full of summaries of studies that we've talked about how we
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can best minimize patients' risk. Nobody has ever zero percent risk for something bad
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happening to them during an operation. And it's not that these problems don't exist
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for people that aren't taking these medications. Bad diabetics, type 1 diabetics often have
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what is called gastroparesis where their stomach, food doesn't move through their GI system
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as it is. And so you may have this kind of combination of issues that are happening where
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you're not sure whether this is from the gastroparesis, from the medication-induced gastroparesis
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or from some other problem that these people are having or whether they were simply non-compliant
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with the directions that they got. So there's guidelines that come from all different organizations
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that are telling us some similar things and some different things. And what we at our
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institution here in Cincinnati have done is try and provide the best guidelines to
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patients and to surgeons and anesthesiologists to minimize their risk of something bad happening
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while maximizing the risk that they can get this procedure or treatment that they need
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in order to further their healthcare journey. So if they need a colonoscopy for their health
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screening, we want to minimize the risk that they're going to aspirate during that or that
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somebody is going to cancel it. If somebody has colon cancer and they need their colon
22:42
removed, we want to make sure that they're going to have it done as they plan it. I understand
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that patients make lots of plans around surgery. They take time off from work. They get rides.
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They do all those other things. It's expensive to be here. We want to get people through
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surgery in a timely fashion and get them the treatment that they deserve while giving them
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the best possible chance to have a good outcome on the backside.
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So what should we tell patients who show up to clinic who might be on one of these medications?
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Is there an amount of time that we should hold them or should we continue them?
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We are still looking into exactly how we're supposed to do this. We need to better understand
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the glycemic control, the blood sugar control that goes on with these medications. The biggest
23:26
problem with these long acting medications like the Ozempic and the Mongero are that
23:33
they have a, the terzepatide has a five day half life and semaglutide has a seven day
23:38
half life. Typically when we talk about getting medications out of the system, we talk about
23:43
waiting for half lives. So you're talking about telling somebody to stop taking these
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medications for a full month, which oftentimes we don't have that kind of lead time to even
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begin with. So I don't see somebody, don't always see somebody a month in advance of
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their surgery in order to be able to tell them to stop it. Oftentimes you don't have
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that time to begin with. If somebody has a screening colonoscopy and they turn out to
24:05
have colon cancer and they need that resectin and it needs to happen, we're not going to
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wait four weeks just to empty out, to make sure that the stomach is empty.
24:13
Currently what the American Society of Anesthesiologists recommends is that you hold the week prior's
24:17
dose of a long acting week long medication or once a week medication. It's not really
24:26
clear that that is reducing people's risk because you're not getting to a lower serum
24:35
level of this medication in a way that you can reliably say, no, this is no longer having
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an effect on their stomach. What we as our institution have done is we gathered all this
24:47
information, looked through all these studies, talked to a bunch of other academic institutions
24:52
and private institutions to see how they were instituting this. What we ultimately found
24:58
to be the lowest risk thing to do is to hold the medication for at least a week beforehand
25:05
and then institute a clear liquid diet for the 24 hours before the procedure. Clear liquids
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isn't just water but it's any carbonated soda, broths, jello, things that don't have pulp
25:19
free juices, things like that, that would still have enough sugar and calories to sustain
25:24
you through the day. You're probably going to feel pretty hungry but it's not like you
25:28
can't eat anything at all. The point of that is to put things that are easy to move through
25:33
the stomach, even with delayed gastric emptying, with slow gastric motility, put light things
25:39
in the stomach that are going to move through quickly. Then we have a strict eight hour
25:43
NPO time that we give people before surgery. There are other things within the ASA guidelines
25:49
for people that are not on these medications where they can have clear liquids two hours
25:53
beforehand, a light meal six hours beforehand. Take all of that and say the safer thing to
25:58
do for you, the lower risk thing to do for you is to say, don't put anything in your
26:03
stomach at all for eight hours prior, except maybe some sips of water with some medications
26:08
that are necessary that you need to take prior to surgery. Beyond that, so if people follow
26:14
these guidelines, they hold the medication for the week beforehand, they follow the diet
26:18
appropriately and then if they show up on the day of surgery, there's an evaluation
26:23
that should happen by the anesthesiologist as to whether they are having any signs of
26:28
bloating or GI upset. So do they feel nauseated? Do they feel like they need to throw up? If
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they do feel the need to vomit or they feel like they're bloated, they feel like their
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stomach isn't empty, we can perform a gastric ultrasound, point of care ultrasound or POCUS.
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So what we do with that is look at the upper abdomen, evaluate the stomach, see if there's
26:47
any solid contents in it, liquid contents in it, and follow a formula or algorithm to
26:53
determine whether this should be considered a full stomach or not. Once we've determined
26:59
whether they have a full stomach by ultrasound or if they don't have these symptoms, we just
27:03
proceed on to the next step of this algorithm, which is to decide what the lowest risk type
27:08
of anesthetic would be for them. For some patients who are having very time sensitive
27:12
surgery, so cancer surgeries, emergent surgeries, those people should proceed to surgery with
27:18
aspiration risk. So this would be as though somebody didn't follow NPO guidelines at all.
27:24
This is like before all of the GLP-1 agonist stuff started, there were people that we took
27:29
to surgery despite the fact that they violated their NPO guidelines because of the overall
27:34
risk of waiting was worse than the risk of proceeding with a full stomach. So things
27:40
like doing rapid sequence intubation to minimize the risk of gastric regurgitation and pulmonary
27:47
aspiration. Beyond that, we really don't have a whole lot that goes much further than that,
27:55
rather than potentially delaying somebody if the surgery is not time sensitive and that
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they are not or if they are not willing to accept the risks of undergoing this procedure
28:06
with potentially a full stomach.
28:09
So how did you learn how to do gastric ultrasound?
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There's an ASA course on point of care ultrasound where you do some didactic learning. You learn
28:19
the kind of physics and mechanisms that go into ultrasound. And then ultimately it's
28:26
just putting your probes on people, getting the curvilinear probe, putting it on people
28:30
in pre-op and seeing what a normal empty stomach looks like. As I've taught this to people,
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I've really found that people struggle, that our learners struggle to find a full stomach
28:44
because so many people that we see in pre-op are appropriately NPO, don't have anything
28:49
in their stomach and that nice tight little stomach sitting behind the liver is very easy
28:55
to find. Sometimes after I have lunch, I'll go down with my learners and say, find my
29:00
stomach and they can't find it because the stomach is grossly enlarged with my lunch
29:07
sitting in there. And it can be so profoundly different than what you're used to seeing
29:12
that you've really got to see some full stomachs in order to see what the whole thing looks
29:17
like. So it's a little bit of didactic learning and then experience, experience, experience,
29:22
experience. You have to see empty stomachs, full stomachs, everything in between. Do it
29:27
to yourself, do it to friends, do it to neighbors, do it to your patients, whatever. You just
29:31
need to get your hands on probes, put the probes on bellies, evaluate those images and
29:36
see what you can find.
29:37
Shout out to Mark Pies on our hospital cafeteria for providing us with full stomachs.
29:42
Mark Pies is profoundly easy to find with gastric ultrasound.
29:47
That's good to know. Okay. So once we have hopefully intubated these patients successfully,
29:56
do you think that it is worthwhile to put an OG or an NG tube in these patients versus
30:01
a standard patient? Or is there a role for OG or NG prior to going off to sleep?
30:07
I have never placed a preoperative OG or NG. I think that that's a very big ask of patients,
30:15
especially if you don't have a really good indication.
30:19
Sure.
30:20
I was taught as a resident that you could do this for small bowel obstructions and things
30:24
like that where you're really worried about the possibility of a very full stomach from
30:30
bowel obstruction and the possibility of regurgitation and aspiration. I was also taught by some
30:38
of our more experienced colleagues when I was an early learner that anybody that gets
30:44
an RSI for the beginning of their procedure should get gastric decompression. In my modern
30:52
practice, I find that that's maybe 50-50 with the younger cohort of people that I work with.
31:00
I have looked for studies on this and have not found any real guidelines or evidence
31:04
to say that this reduces people's risk. But I would caution people that are not doing
31:10
OGs or that in general are doing RSIs because patients have taken these medications and
31:17
may not have been compliant with it or whatever. You're worried about a full stomach. You continue
31:21
to consider that throughout the case and you don't do things like deep or anesthetized
31:25
exubation that you make sure that airway reflective reflexes have returned before you go ahead
31:31
and remove your airway securement device. Or that you don't do things like consider
31:37
LMAs for these procedures because I think that that is hard to justify if you're so
31:43
worried about an empty stomach or about a full stomach but then you're going to not
31:48
put in a secure airway. I think that's really hard to look back on and say, why did I do
31:53
this and to be able to justify what you did. That makes a lot of sense. While zooming out,
32:01
what advice would you give to anesthesiologists generally who are increasingly encountering
32:06
patients treated with GLP-1 agonists? We need to know more. We need to study more. We need
32:11
to see more. We need to do more. We need to be able to really evaluate what holding these
32:18
medications does for people, which right now we're just telling people not to take them.
32:23
We don't really know what's happening from a glycemic control standpoint there. We need
32:27
to work better with our endocrinology colleagues to find out what happens when you stop taking
32:32
these medications. We need to get more of a patient experience involved in this as well
32:38
to see what they are feeling when they're stopping these medications and see how those
32:42
things are moving along for them and see how they're feeling when they're not taking them.
32:47
Then we need to continue to gather information about the risk of aspiration. Lots of people
32:53
have lots of institutions have very different policies and protocols related to this. We
32:58
need to do a big global overview of what policies are working. I think that overall when you
33:06
review anesthesia literature that the incidence of regurgitation and aspiration is overall
33:13
low. I am suspicious that that is artificially low. I believe that there is aspiration that
33:19
goes on that we may not be catching. It may be either we are not seeing it, we're not
33:23
recognizing it, or it's simply not clinically significant enough to matter. All of those
33:28
things are real problems and things that we can improve upon. But I think that similar
33:34
to when you look through some of the literature about awareness monitors that the overall
33:40
it's very difficult to show any improvement with those things because the overall incidence
33:45
of awareness and surgical recall is so incredibly low with modern techniques. I think that the
33:50
overall incidence of aspiration is so incredibly low that it's hard to find big increases in
33:57
that. When you look at some of these studies that have been done on people that are taking
34:04
GLP-1 agonists, you find that there are increased gastric content, retained gastric contents
34:10
in about 1% more of patients than people that aren't taking these medications. That doesn't
34:15
sound like a lot, but the overall incidence of aspiration being so incredibly low means
34:21
a 1% increase could be a multi-fold bloom in people that are having aspiration, having
34:29
a pneumonitis, getting a pneumonia. I don't think that we should overlook those relatively
34:33
small numbers because even small numbers can have a big impact on patients as we move forward.
34:39
Do you have any recommendations for folks that might want to do some further reading
34:43
on this topic?
34:46
The ASA guidelines, I think, are somewhat on the vague side because I don't think that
34:50
we have enough data in order to really give firm guidelines that say this is exactly what
34:57
you're supposed to do. There are tons of studies on these medications. There are studies that
35:03
I work on or that look at the effects of the different medications over time. I think that
35:10
my recommendation would be to look up some of these studies on the basic biomechanics
35:17
of what these medications do in the body and what happens over time, what happens as you
35:25
use these medications more and more. Just to continue to keep an open eye out for emerging
35:33
studies for new studies that really take a look at, that go beyond the case reports,
35:38
that go into more of the real science and big collection of data, collection of big
35:47
data of what these medications are doing to people.
35:52
You said in the past that you've attributed all your success to my brief mentorship of
35:57
you during your CA3 year when I was a first year attending.
36:00
I've never said those words before.
36:02
I agree to disagree. Beyond that, what style points or points of personal preference have
36:08
brought you success in your career in and out of the operating room?
36:11
You have to care. You have to care about every patient that's in front of you, care about
36:15
all of your colleagues. You have to care about yourself. You have to care that everybody
36:20
is here for the common good. Everybody is here to make people better. Everybody is here
36:26
because they want to be. When a patient tells you that they have a problem, you have to
36:31
care that they're not lying to you. You have to care that they are here because they want
36:35
to get better and you are here to make them better. You are here to give them what they
36:40
need to get better. I'm going to change that just a little bit.
36:44
Early in my medical school career, we had a lecture in which they said, you don't heal
36:49
people, you provide them with the tools to heal themselves. So you need to care enough
36:56
that patients feel that you care about them and that you want them to get better and that
37:02
you want them to have a good experience. This is every day for me is showing up and providing
37:08
anesthetics for people and getting people through the preoperative time. And every once
37:13
in a while you find yourself overlooking things because you've started to not care about things.
37:21
And when you don't care, it really affects the way that patients look at you. It affects
37:26
the way that your colleagues look at you and the way that they think about you. You have
37:31
to remember that every patient that is having surgery, you know, the saying is there's no
37:36
minor surgery that happens to me. So even something that seems very minor to you as
37:42
the provider may be the worst day of this patient's life. It may be the most physiologically
37:49
challenging thing that they've ever gone through. When you look at a routine surgery, it is
37:54
going to be the hardest thing that this person's body has ever faced. Without anesthesiologists,
38:02
without anesthetists, without residents that are involved in these patients' care, they
38:06
would not survive most routine surgeries. Physiologically, they could not tolerate it.
38:13
We are here to keep them safe. We are here to provide, to prepare them, to provide for
38:17
them and to get them ready to heal themselves when it's time to get out of the hospital.
38:21
So my style point is that you have to care. You have to treat everybody like that's the
38:25
most important person in front of them because to them, this is the most important day of
38:29
their life.
38:30
Peter, thank you so much for joining us. I really enjoyed our conversation.
38:34
Thank you very much for having me here.
38:38
That's it for today's episode of Style Points. Feel free to like or subscribe. If you'd like
38:43
to contact me or even be a guest on the show, feel free to email me at stylepointspodcast.gmail.com.
38:49
Remember, what you're doing out there every day is really important and valued. Wait a
38:55
second, wrong podcast. I guess I'll have to come up with a different tagline. Okay, I
39:01
think I've got it. We're all done. Open your eyes.