ASA’s Task Force on Preoperative Fasting suggests the following for patients taking GLP-1 agonists for type 2 diabetes or weight loss who are having elective procedures. It is also calling for further research to be done regarding GLP-1 agonist medications and anesthesia.
Day or week prior to the procedure:
Hold GLP-1 agonists on the day of the procedure/surgery for patients who take the medication daily.
Hold GLP-1 agonists a week prior to the procedure/surgery for patients who take the medication weekly.
Consider consulting with an endocrinologist for guidance in patients who are taking GLP-1 agonists for diabetes management to help control their condition and prevent hyperglycemia (high blood sugar).
Day of the procedure:
Consider delaying the procedure if the patient is experiencing GI symptoms such as severe nausea/vomiting/retching, abdominal bloating or abdominal pain and discuss the concerns of potential risk of regurgitation and aspiration with the proceduralist or surgeon and the patient.
Continue with the procedure if the patient has no GI symptoms and the GLP-1 agonist medications have been held as advised.
If the patient has no GI symptoms, but the GLP-1 agonist medications were not held, use precautions based on the assumption the patient has a “full stomach” or consider using ultrasound to evaluate the stomach contents. If the stomach is empty, proceed as usual. If the stomach is full or if the gastric ultrasound is inconclusive or not possible, consider delaying the procedure or proceed using full stomach precautions. Discuss the potential risk of regurgitation and aspiration of gastric contents with the proceduralist or surgeon and the patient.
Full stomach precautions also should be used in patients who need urgent or emergency surgery.
It seems that ever since that advent of dexmedetomidine, propofol has been pushed aside as the sedation drug of choice for sedation during and post-open heart surgery. But is the literature changing with the effects of dexmedetomidine on rates of atrial fibrillation?
In patients older than 60 years with low baseline risk of postoperative delirium admitted to the ICU after cardiac surgery and extubated within 12 h of ICU admission, a post-extubation nighttime dose of dexmedetomidine may reduce the incidence of delirium on postoperative day one.
The study results showed no statistically significant difference between both groups with regard to age and body mass index. Group P patients were more associated with lower MAP and HR than Group D patients. There was no statistically significant difference between groups with regard to ABG findings, oxygenation, ventilation, and respiratory parameters. There was significant difference between both the groups in midazolam and fentanyl dose requirement and financial costs with a value of P < 0.05.
Meta-analysis studies on the use of DEX during cardiac surgery also showed a reduction in the risk of atrial fibrillation, ventricular tachycardia and cardiac arrest [7, 12].
Our findings suggest that DEX may reduce short term postoperative pulmonary complications, time on mechanical lung ventilation, ICU and hospital stay following CABG surgery compared to propofol.
When compared with propofol, dexmedetomidine sedation reduced incidence, delayed onset, and shortened duration of POD in elderly patients after cardiac surgery. The absolute risk reduction for POD was 14%, with a number needed to treat of 7.1.
Dexmedetomidine did not significantly impact ICU length of stay compared with propofol, but it significantly reduced the duration of mechanical ventilation and the risk of delirium in cardiac surgical patients. It also significantly increased the risk of bradycardia across ICU patient subsets.
The use of dexmedetomidine for sedation after cardiac surgery was associated with a lower incidence of atrial fibrillation and hence decreased the duration of intensive care stay.
This trial demonstrated that dexmedetomidine sedation may be better able to improve microcirculation in cardiac surgery patients during the early postoperative period compared with propofol.
Adding low-dose rate dexmedetomidine to a sedative regimen based on propofol did not result in a different risk of in-hospital delirium in older patients undergoing cardiac surgery. With a suggestion of both harm and benefit in secondary outcomes, supplementing postoperative propofol with dexmedetomidine cannot be recommended based on this study.
Dexmedetomidine infusion, started at anaesthetic induction and continued for 24 h, did not decrease postoperative atrial arrhythmias in patients recovering from cardiac surgery. Dexmedetomidine also worsened delirium, although not by a significant amount, possibly by provoking hypotension. Dexmedetomidine worsened kidney injury, but again not by a significant amount. The incidence of persistent surgical pain was similar in each group. Dexmedetomidine should be used cautiously in cardiac surgical patients with attention to preventing hypotension, and should not be given in expectation of reducing atrial fibrillation or delirium.
Dexmedetomidine-based sedation resulted in achievement of early extubation more frequently than propofol- based sedation. Mean postoperative time to extubation and average hospital LOS were shorter with dexmedetomidine- based sedation and met a statistical level of significance. There was no difference in ICU-LOS or in-hospital mortality between the two groups. Total hospital charges were similar, although slightly higher in the propofol group.
One means of achieving a balanced resuscitation is with the use of WB instead of component therapy. The combination of plasma, PLT and PRBC components in a 1:1:1 ratio is estimated to result in a HCT of 25%, coagulation factor activity of 62%, platelet concentration of 50×109/L, and fibrinogen concentration of 75 mg/dL. In comparison, a unit of fresh WB has a HCT of 45%, 100% activity of all coagulation factors, platelet concentration of 200×109/L, and fibrinogen concentration of 150 mg/dL
The American College of Obstetricians and Gynecologists (ACOG) recommends fixed product ratios (65). This practice is supported by retrospective studies that demonstrate, in combination with a comprehensive post-partum hemorrhage protocol, MTP is associated with improvement in transfusion needs and peri-partum hysterectomy (66–68). Additionally, obstetric hemorrhage protocols should focus on repletion of fibrinogen via early administration of CRYO or fibrinogen concentrate, as fibrinogen is the first coagulation factor to diminish in post-partum hemorrhage
In addition to blood transfusion during MTP, several useful pharmacologic adjuncts to resuscitation have been identified. These include calcium repletion, tranexamic acid (TXA), factor VII concentrate, prothrombin complex concentrate (PCC), and arginine vasopressin (AVP). In addition to pharmacologic adjuncts, the use of viscoelastic testing can help improve blood product utilization and outcomes.
One in 455 blood components transfused is associated with an adverse event, but the risk of serious adverse reactions (1 in 6,224) and transfusion-transmitted infections (1 in 255,400) is extremely low in the United States (117). The most common non-infectious reactions include febrile non-hemolytic transfusion reactions, allergic transfusion reactions, transfusion-associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), and acute or delayed hemolytic reactions (118). The effects of blood preservation and storage also cause changes in the quality of the blood over time, including decreased pH, increased potassium, decreased 2,3-diphosphoglycerate (2,3-DPG), and decreases in erythrocyte and platelet function, all of which may affect resuscitation and oxygen delivery (119).
Trigger for FFP and/or PCC in Clinical Recommendations
In the Society of Cardiac Anesthesiology recommendations, transfusion of 10 to 15 ml/kg of FFP or a low dose of PCC (not defined) is recommended when clotting time in tissue factor–activated ROTEM or the reaction time in heparinase TEG is significantly prolonged (table 2).13 Of note, the European recommendations for hemostatic resuscitation in trauma recommend a dose of 25 IU/kg of a PCC, whereas in cardiac surgery patients, an initial dose of 12.5 IU/kg (similar to that suggested by the U.S. recommendations) should be considered because of the inherent risk of thromboembolism.20 In the European trauma guidelines, the authors point out the possible influence of hypofibrinogenemia on clotting time in tissue factor–activated ROTEM.14 Therefore, PCC should be given only when fibrinogen levels are less than 1.5 g/l (corresponding to a fibrinogen ROTEM maximal clot firmness of less than 10 mm), and clotting time in tissue factor–activated ROTEM is prolonged or remains prolonged after replacement of fibrinogen.
− SWB, which will in U.S. military practice be LTOWB, is the preferred product for resuscitation of severe bleeding (both pre-hospital and in-hospital). SWB simplifies the logistics of the transfusion and may facilitate more rapid resuscitation of casualties, and may enhance a facility’s capacity to manage mass casualty (MASCAL) challenges.
− The indication for SWB is life-threatening hemorrhage. The assessment that a hemorrhage is life-threatening is mainly established clinically, and should be driven by an assessment of the patient’s vital signs, hemodynamics, physical exam, mechanism of injury and laboratory measures of shock and hemostasis if available. The use of FWB should be reserved for when SWB or full component therapy is unavailable.
− Blood component therapy (1:1:1) is an acceptable option for treating life-threatening hemorrhage when SWB is not available. The potential reduced efficacy, safety, and logistical aspects of blood component therapy should be taken into consideration when choosing between resuscitation strategies (Table I).
All people with type 2 diabetes should be offered access to ongoing DSMES programs.
Providers and health care systems should prioritize the delivery of person-centered care.
Optimizing medication adherence should be specifically considered when selecting glucose-lowering medications.
MNT focused on identifying healthy dietary habits that are feasible and sustainable is recommended in support of reaching metabolic and weight goals.
Physical activity improves glycemic control and should be an essential component of type 2 diabetes management.
Adults with type 2 diabetes should engage in physical activity regularly (>150 min/week of moderate- to vigorous-intensity aerobic activity) and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks.
Aerobic activity should be supplemented with two to three resistance, flexibility, and/or balance training sessions/week. Balance training sessions are particularly encouraged for older individuals or those with limited mobility/poor physical function.
Metabolic surgery should be considered as a treatment option in adults with type 2 diabetes who are appropriate surgical candidates with a BMI ≥40.0 kg/m2 (BMI ≥37.5 kg/m2 in people of Asian ancestry) or a BMI of 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in people of Asian ancestry) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods.
In people with established CVD, a GLP-1 RA with proven benefit should be used to reduce MACE, or an SGLT2i with proven benefit should be used to reduce MACE and HF and improve kidney outcomes.
In people with CKD and an eGFR ≥20 ml/min per 1.73 m2 and a UACR >3.0 mg/mmol (>30 mg/g), an SGLT2i with proven benefit should be initiated to reduce MACE and HF and improve kidney outcomes. Indications and eGFR thresholds may vary by region. If such treatment is not tolerated or is contraindicated, a GLP-1 RA with proven cardiovascular outcome benefit could be considered to reduce MACE and should be continued until kidney replacement therapy is indicated.
In people with HF, SGLT2i should be used because they improve HF and kidney outcomes.
In individuals without established CVD but with multiple cardiovascular risk factors (such as age ≥55 years, obesity, hypertension, smoking, dyslipidemia, or albuminuria), a GLP-1 RA with proven benefit could be used to reduce MACE, or an SGLT2i with proven benefit could be used to reduce MACE and HF and improve kidney outcomes.
In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or SGLT2i with proven benefit should be independent of background use of metformin.
SGLT2i and GLP-1 RA reduce MACE, which is likely to be independent of baseline HbA1c. In people with HF, CKD, established CVD, or multiple risk factors for CVD, the decision to use a GLP-1 RA or an SGLT2i with proven benefit should be independent of baseline HbA1c.
In general, selection of medications to improve cardiovascular and kidney outcomes should not differ for older people.
In younger people with diabetes (<40 years), consider early combination therapy.
In women with reproductive potential, counseling regarding contraception and taking care to avoid exposure to medications that may adversely affect a fetus are important.