Aspiration risk and strategic approach for patients receiving GLP-1 receptor agonists undergoing elective surgery

Perioperative management of patients receiving a glucagon-like peptide-1 receptor agonist (GLP-1 RA) remains challenging for the anesthesiologist. Despite the approval of GLP-1 RAs 2 decades ago, the recent reports of aspiration and postoperative pulmonary complications drew attention to this group of medications and resulted in multiple societal guidelines that would provide recommendations for anesthesiologists and proceduralists on the appropriate perioperative management of GLP-1 RAs. However, despite these guidelines and proposed options, there was a lack of adequate evidence to support holding versus continuing the medication, as well as data related to the role of gastric ultrasound in that decision-making process. The release of multiple societal guidelines and studies evaluating the impact of GLP-1 RAs on perioperative outcomes resulted in more controversy and uncertainty for the clinician anesthesiologist to follow. The ultimate goal for perioperative management of these medications is to evaluate an individual patient's risk of aspiration, rather than assuming the risk is low when holding the medication appropriately or high if not holding it. Furthermore, it is unclear whether holding these types of medicines or unnecessary postponing of surgery may result in adverse outcomes. In this narrative review, we present a summary of the existing literature on the topic with a focus on the risk of aspiration and a recommendation for perioperative management to include the utilization of gastric ultrasound for surgery patients based on their risks.