The problem with anesthesia & weight loss drugs like Ozempic

[@barbtries]

thank you - I'm on Ozempic and had surgery in January. I don't recall being advised to not take the Ozempic prior to surgery, which was performed one day before my weekly shot. I had no problems with aspiration at any rate, but this is good to know because I'll discuss it next time with my doctor to get clear instructions.

[@PrettyPink7]

I had surgery 3 months ago and I wasn’t told to stop it either.

[@jackbarlow11]

The guidelines were not in place yet.

[@janetk8948]

I just had my pre-surgery visit to Cleveland Clinic and met your med school friend Michael Walters. He was so nice and helpful during a difficult day (too long of a story!). Thanks to you for explaining all of the different aspects of cardiac anesthesia and thanks to him for being there for me yesterday.

[@Bhaventh]

I regularly watch your videos from India. I don't have any medical degree or relationship with the medical field, but your videos have ignited my enthusiasm and curiosity. Basically, I am a civil engineer.

[@dodimichaud8673]

In January 2023, I had general anesthesia for back surgery. I was taking Ozempic and no one told me to stop it although they knew I was taking it. They informed me that there was food in my stomach at the time of anesthesia. I did have a bit of aspiration but it wasn’t consequential, luckily.

[@kyledeitz2760]

It’s fairly new information to the anesthesia world. We just started implementing the policy where I work.

[@sandrawilson8337]

I am on ozempic and just had a colonoscopy. I don't remember any issues, but no one told me to hold the ozempic. This is very important to me.

[@kyledeitz2760]

@@sandrawilson8337 yes, it’s just now coming about in the anesthesia world and being communicated to the Gastroenterologists. But yes, from now on hold your glp 1 antagonist(ozempic) for a week for safety. And make your primary care physician aware if you are on it for diabetes incase he wants to prescribe something to bridge the gap. Obviously if it’s only for weight loss, just restart it after the procedure.

[@billydunwoody]

I was on Mounjaro and had surgery in March. MAC. No one ever told me to not take my Mounjaro and neither my surgeon nor anesthesiologist was concerned about the drug. Luckily nothing happened. Now I am on Ozempic and will definitley remind my doctors if I ever have surgery again.

[@MaxFeinsteinMD]

These guidelines actually came out after March.

[@brettlamont4965]

What about people with gastroparesis? Are they advised a longer period of no food or water?

[@laurmichelle9560]

I’ve had very severe Gastroparesis (chronic delayed gastric emptying) for 15 years, since I was 13, and I CANNOT stress how important everything you mentioned in this video is enough! Even though I solely rely on tube feeds and TPN, my anesthesia plan often changes/is dependent on how nauseated I am on the day of the surgery or procedure, and if we believe I have an excessive amount of bile or acid in my stomach that we can’t drain out of my G tube completely, we opt for general over MAC, but MAC is always the default so we have the option to switch over if there are any issues. Thank you as always for getting the critical information out there!

[@sharpnicolecatherine]

Same, I have a feeding tube but eat some by mouth and I'll say I've NEVER been told to fast for longer than the 8 hrs or npo after midnight they usually have people with normal gastric emptying even tho they've found old food or bezoars with egds when I listened to them, had to figure out on my own

[@laratheplanespotter]

Same here. Jej fed for 5 years here. Why anyone would want it idk

[@chuck1933]

Max. Come to Wisconsin. Awesome Health Systems here. You could lead anesthesiology or any department you chose to. At any hospital or hospital system here. We would be honored by you coming here

[@darriontunstall3708]

Wow that was awesome and amazing ! I learned so much!!! I really enjoy donating to the anesthesiologist Foundation, since it was hard for me to go to college because of my cerebral palsy, I really wanted to be a anesthesiologist physician! I always learn a lot from you! You rock man

[@scrumptious9673]

Very admirable 👏

[@darriontunstall3708]

@@scrumptious9673 thanks

[@knnzzzz]

Would Reglan help in cases like these? ex: patient needing emergency surgery but was on a GLP1 med?

[@karimaogden3875]

You should be very careful with taking it.Reglan(Metoclopramide) is a very dangerous drug and it could cause serious side effects like Tardive Diskinesia, which involves involuntary movements of the face, mouth, eyelids and chin and also occurs in people taking psych meds like antipsychotics, mood Stabilizers, etc It's also been known to cause Drug-Induced Parkinsonism.Thankfully, those side effects usually go away after the drug is withdrawn.The problem is that most doctors, including surgeons and anesthesiologists don't know or don't think it's necessary to tell their patients about those side effects, so when the patient start exhibiting symptoms, they will attribute it to other cause and start adding more meds to control the symptoms which will create a down spiral.

[@smariec2021ify]

Thank you! 6:37

[@frotoe9289]

Interesting. Seems like this would also make things like colonoscopies tougher. Having had a couple, it's already not fun. They demanded I not eat a thing for like... 32+ hours before the procedure? (going from memory, it was "stop eating by midnight, don't eat next day while doing the "cleanse" and then get the procedure somewhere between 8am and 2pm.) It would really suck if you had to extend that another day because your stomach empties slowly.

[@GreggBB]

Thank you---really great information. You help us realize how complicated, on so many different levels, it is to safely and effectively provide anesthesia for various surgeries.

[@tarablum3089]

I had surgery yesterday morning, and I take Ozempic. I did not skip my dose, since it was due yesterday evening (I take it weekly). Because I take Ozempic, I had to have general (endotracheal) anesthesia, but I was also told they put in an orograstric tube to make sure I had nothing in my stomach.

[@70acres]

I am, unfortunately, all too familiar with this. I have Gastroparesis, Esophageal Immobility Disorder AND I take Rybelsus for my Type 2 Diabetes. My stomach just never really empties.

[@igibon8]

I am a physician assistant anesthetist working at Atlanta. I had to intubate a patient who had BMI close to 50 for her eye muscle surgery at an outpatient surgical center. The rationale is the patient is on Ozempic. Normally, we only use LMA for this type of surgery.

[@MrLaurichu]

definitely need intubation, need to withhold the drug too

[@izabelbrailovsky7560]

@MaxFeinstein can you talk about managing airways during anesthesia for patients with severe motility disorders. I have severe gastroparesis and chronic intestinal pseudo obstruction and am TPN dependent. What does managing anesthesia and airways look like for patients like myself?

[@Trinket2022]

Thank you for getting this out there..im on ozempic and fortunately read about this before an mri which i was told to fast for. I had to call them and explain this whole thing..they hadnt heard about it!

[@IAMdevilwomen]

this is VERY scary! I am on ozempic .2 for my type 2 diabeties, the weight loss was a bonus, I've lost 50 pounds so far, but that is not why I was put on it, my A1C was high and this got it from 8.9 down to 6.7, I am currently fighting cervical/uterine cancer, however on the 29th I go in for a ct scan to see if tumor shrunk, if it has, I see oncology Dr on the 31st for the results, if it has, surgery to remove it...hearing this scares the crap out of me, I'm already fighting for my life, but to find out that the surgery to save my life could end it, IDK what to do now

[@jhonbus]

If you bring it up with the anaesthetist then they'll be able to check if your stomach is empty before any surgery, and they can take steps to reduce the risks if they know to do so.

[@FakeMaker]

Definitely tell all of your concerns to the anesthesiologist, I'm sure they'll take it into account and take precautions/monitor certain things more. I also want to wish you only the best and that things go smoothly for you.

[@IAMdevilwomen]

@@FakeMaker thanks, will find out on the 31st if I can get tumor removed...fingers crossed

[@andrewleibowitz2677]

In many hospitals there are new guidelines...that may include drug cessation for > 1-2 weeks, and a longer NPO period before surgery.

[@IAMdevilwomen]

@@andrewleibowitz2677 ok so if so I hope they let me know and I will make sure I don't take it for the recommended time frame

[@Ms.Opinionated]

As always, great information.

[@wong90210]

Doctor Max: Is IV raglan still used in cases of delayed gastric mobility?

[@jaybertulus]

how about a video about the anaesthesia machine ie circuit. what happens at minFlow etc

[@rachelliz4786]

I have idiopathic gastroparesis (aka delayed gastric emptying for an unknown reason) and have a feeding tube cause i cant eat enough to keep myself alive. before i got my tube i wasnt allowed to eat for a minimum of 24 hours before anesthesia but now that i have my tube i only have to fast for the normal amount of time. this is because my tube goes into my stomach through a hole that was surgically made from the outside of my belly to the inside of my stomach then the tube goes down into my jejunum (a part of the small intestines). In my tube there is a port that i use to put things into my intestines like my meds and formula and a port that i can use to put things in and take things out of my stomach (but i almost never put things in cause it hurts) and that port allows my to "drain" or suck the contents of my stomach out whenever i need to. because im able to drain my stomach im able to eat for pleasure/funsies and empty my stomach when the pain and nausea starts and on days that i have surgery i am able to drain my stomach once at home and again at the hospital to make sure i have nothing in my stomach before surgery. and thats the very long story on why i can fast the normal amount of time even though my stomach is super slow

[@salman3920]

Very informative. Thank you very much

[@ashleyferguson6589]

Wow, interesting! Congrats! SIX years post-op here! I've been through the weight loss, the regain and the re-loss. It is a journey! Charting my stats helped me, majorly! I even created a FREE planner/tracker to share with anyone that would like to try it

[@benjyfiles465]

Are there similar guidelines for people who have delayed gastric emptying for other reasons (eg idiopathic gastroparesis)? I had a colonoscopy a few years ago, and the prep was retained in my stomach due to my gastroparesis. They went ahead with the procedure.

[@knzay]

Yup, one of my abdominoplasty patients who was on wegovy puked during the case- anesthesiologist was not pleased

[@badgeblingcscrissawyerbsnr2137]

So good. Thank you

[@barrykamin8776]

Translation to reality means that individuals receiving GLP-1 medications and undergoing procedures previously handled with conscious sedation alone, e.g., colonoscopy, will need to receive a general with an endotracheal tube.

[@MaxFeinsteinMD]

Potentially. Or at least have gastric ultrasounds done to evaluate gastric contents.

[@amandajames5351]

Very interesting. I take mounjaro amd was told to stop taking ot 2 weeks before my recent surgery. I was told it was because my blood glucose could drop. Whatever the reason, all went very well with my procedure.

[@scrumptious9673]

Glad to hear it went well

[@bradowen761]

Just curious, did you experience weight gain, increased hunger, or any other symptoms when you stopped?

[@amandajames5351]

@@bradowen761 Yes. In fact, I gained 10 pounds.

[@lyubovzaslavskaya2915]

Thanks. It was very informative. And information was extremely important

[@mrrishiraj88]

Thanks

[@rcom9880]

What about residual stomach acid and other normal gastric secretions still present in absence of food in a pre-op patient?

[@chsovi7164]

"this video is likely already outdated by the time you're watching it" me, watching 4 hours after posting: hmmmmm interesting *heads to google scholar*

[@gothafloxacin]

I have severe gastroparesis from a mitochondrial disorder. This has always been my normal precautions.

[@infopubs]

Super interesting topic!

[@thomasbeatty9496]

Great video Doctor Feinstein. Thank you.

[@gloriajurney1956]

Curious whether it’s ever appropriate to pump a stomach of its contents just prior to surgery to make a safer condition for anesthetic?

[@sexybandboy]

I was thinking the same thing. Would it not be more beneficial to use an OGT to decompress the stomach rather than delay surgery?

[@kyledeitz2760]

I’m a nurse anesthetist. This is a very good question. The problem with suctioning the stomach out, is that a lot of the times there is still solid food present with these patients which can’t be auctioned out through an NG tube. The only reason I know is seeing for myself. Now we just stick to the guidelines of holding the medication long enough for elective surgeries. For emergencies, we place a tube in the airway anyways to protect from stomach contents.

[@Monica-gj2yx]

Having the stomach pumped is very uncomfortable.

[@lilbatz]

I have to go for adrenal vein sampling in a month. Was told 2 weeks off of Trulicity and clear liquids the day before. Gas brohs aren't playing anymore with these meds.

[@jojackson9129]

You've not mentioned manually pumping the stomach to empty it of food or liquid. I don't know anything about it, other than non-medical comments in relation to overdosing or ingestion of toxins. Can you comment on that and explain why it's not an option? Thanks!

[@MaxFeinsteinMD]

That entails putting a plastic tube down a patient’s nose all the way into the stomach. It’s quite uncomfortable and itself can lead to vomiting. Typically just reserved for certain emergency situations where a patient has a full stomach but the surgery must occur right away.

[@gregcoldewey7724]

I understand the issue you are discussing, so how do you manage emergency surgeries where the patient has not fasted at all?

[@irgilligan]

Rapid sequence intubation.

[@Metroid250]

I believe the stomach is manually emptied with some sort of vacuum inserted in the esophagus. And then frequent monitoring during the procedure. They wouldn't just let the food there because it presents a real risk of suffocation

[@irgilligan]

An orogastric tube is placed in many procedures, but that is done after intubation. The actual induction of anesthesia would be utilizing rapid sequence intubation.@@Metroid250

[@skulqerX]

we can do various procedures to try to minimize the risk . but still have to be done as it is emergent. so the question lies if its not an emergency would we like to risk it to the patient ? hope that clears up

[@KadeSuchan]

I used mounjaro, and last year I had some seizures that were really bad so I was emergently intubated. When they attempted extubation several days later, I vomited intensely. I tried to tell them the mounjaro made my stomach empty slow, but it was so new nobody really knew.

[@bradowen761]

Were your seizures linked to the Mounjaro?

[@KadeSuchan]

@bradowen761 no, it was not. It was just an unfortunate effect that they didn't know about yet I went back on the mounjaro about a month after getting home.

[@emom358]

What is done for emergency patients? Do you have to pump their stomach before surgery?

[@garyjsimm]

Max, doesn't the endotracheal tube protect from aspiration pneumonia ?

[@hockidogrel]

Yes but at the time of induction the patient is anaesthetised with medications and it takes some time between the patient losing co sciousness and the endotracheal tube being placed. Depending on the drugs used laryngoscopy and intubation can occur up to around 3 minutes after induction. During this time the patient is mask ventilated. It's in this time regurgitation and aspiration can occur. In addi tion not every patient having minor procedures gets an ETT: there are also supraglottic devices - though this wouldn't be appropriate for patients at high risk of aspiration. For high risk patients there are "rapid sequence techniques" that can be used to speed up the induction and time to intubation and try to minimise the time in which the patient is most at risk of aspiration. They arent foolproof though! Hope this helps!

[@garyjsimm]

@@hockidogrel got it! Thank you

[@ChrisSmith-rm6xl]

Is pumping out the contents of the stomach a reasonable option?

[@MaxFeinsteinMD]

Only reasonable if the patient is willing to accept a plastic tube, going down their nose into their stomach while awake.

[@frotoe9289]

This video makes it look like a piece of cake: kzbin.info/www/bejne/Z4DEnKCuj6mUa8U But I've also seen videos of patients who bucked and fought.

[@ilovetotri23]

Interesting! Thanks.

[@jarls5890]

Very fascinating info Max!! A question: Would it be an option to "force" the stomach empty before surgery either through inducing vomiting in the patient some time before the procedure or when that is not possible "suck" the stomach empty mechanically just after anesthesia is induced? I mean there must be plenty cases of anesthesia and surgery on a "full stomach" when you have no option to wait - such as traffic accidents etc. Also I think you have shown us the "breathing tube" that is inserted into the patient just after the patient falls asleep that has a small balloon that inflates and effectively seals off the area so no foreign elements can enter the lungs? Why not "always" use that in such cases? OK that was more than one question!

[@DroeGaming]

I'm only a layperson, but it's my understanding that almost all endotracheal tubes do have the inflatable cuff to minimize aspiration. To my knowledge, the only time a cuff is not used is in certain pediatric cases like some premature babies.

[@igibon8]

There is a way to intubate someone with full stomach called Rapid Sequence Induction. In other words, we put cricoid pressure on patient’s neck to prevent patient’s stomach contents to reach vocal cord which is the opening to trachea. But there is no guarantee this step is going to stop the food content to go down to trachea though. NPO is probably a much better way to prevent aspiration pneumonia.

[@jarls5890]

@@igibon8 Very interesting! Never heard about this technique! But - why is not "stomach pumping" an option? I know this is done in cases where poison or drugs have been swallowed.

[@gothafloxacin]

You can suction things out of the stomach with certain machines attached to an NG or G tube. If they are too solid or too thick though it won't work.

[@MrLaurichu]

1) suction cant gaurentee a empty stomach despite the maximal effort used as there are always food debris/fluid remaind and gastric secretions/acid continously produced in the stomach no matter how long you have fasted. 2) uncuffed tube is reserved for children

[@bugsy74]

I had a small procedure done on my back. And the Anesthesiologist almost rescheduled my procedure when she found out I was on mounjaro! Luckily I was fasted about 48 hours at that point

[@jhonbus]

Wow, delaying stomach emptying for TWO DAYS!? That's crazy! You could turn a glass of milk into a block of cheese in that time! I wonder if this has caused any issues with oral medications not being absorbed as expected. Most stuff will probably absorb OK but what about stomach irritation from aspirin/ NSAIDs. A gastro-resistant coating isn't going to help if the tablets are sitting in your stomach literally all day... And how about meds that don't absorb or function correctly if they're not at a high enough pH?

[@athompso99]

Short answer: oh, hell, yes. I have chronic gastroparesis due to diabetic autonomous neuropathy, and my twice-daily fistful of pills definitely do not absorb at a predictable or consistent rate. It makes disease management a lot harder on an ongoing basis, not just before anæsthesia.

[@lizreszke6183]

Delayed gastric emptying... Something called Gastroperisis, which I fell ill with in 2018 and have been tube fed with an NJ feeding tubr since 2020. My gastric emptying study showed delayed emptying and diagnosed me with Gastroperisis. Mine is idiopathic, but you cab get it from diabetes, abdominal surgery due to the vegas nerve being injured.

[@Eman1900O]

After off getting weight loss surgery. Most people don’t keep the weight off after these drugs

[@emgs413]

Koko wings - first-ballot hall of fame call meal

[@geeksky4870]

Interesting, no mention of NPO status pushing a patient into DKA with a normal blood sugar.

[@jhonbus]

Not really what the video is about, I guess, but I didn't know this was even a thing, so I'm glad I saw your comment. Definitely something to be aware of for those with T2D and low endogenous insulin production. (And T1D, although it appears these drugs are contraindicated for T1D at least partly for this reason.)

[@geeksky4870]

Well if they don't stop these meds, then go NPO it can instigate ketosis

[@jhonbus]

@@geeksky4870 Presumably the risk is pretty low given the short time periods people fast for before surgery though?

[@smokeytwitchsmokey]

Noti gang 💯💯 Best way to start the day

[@BedStuyDOD62]

My hospital just instituted policy on these drugs.

[@icantgetridofthisusernamehelp]

Me, who just started Ozempic for my diabetes three days ago: 👁️👄👁️

[@tiffanyhester8595]

So…I will say I have seen a lot of comments for this video which basically state “wow, I had surgery with this medication and was not told about the adverse side affects.” These are still very new medications on the market that are gaining a lot of traction for weight loss, so there is still a lot we do not know about them. Don’t discredit you doctors!!! The only small problem I have with this video is the statement “type 1 diabetics do not produce enough insulin.” In the grand scheme of the disease yes, we don’t produce enough insulin 😅. But the absolute truth is we will eventually not produce any insulin as a result of an autoimmune disease killing off our beta cells in our pancreas. While for type 2 patients, the increase in insulin production from these medications is beneficial, the benefit for me is the delayed gastric emptying, slower digestion, and slower absorption of carbs. Also, having fewer/smaller meals that I have to give myself insulin for is a huge cost saver, since insulin is so expensive (even after my deductible, insulin can be $100 a month where Ozempic is only $25 a month). However, overall that does not take away from the overall theme of the video which is to say we either need to increase NPO time for these patients or decreasing medication before surgery. Also Max if you see this can you one day talk about how anesthesiologist take care of emergency surgeries when a patient was not able to be NPO? Do you pump the stomach always or do as this video suggest and take an ultrasound of the stomach prior to surgery?

[@kingtrevi]

hey dr. feinstein how can we can a jacket like yours lol

[@paulpoppenfuse7071]

❤❤❤❤

[@Legacyyyyyyyyyyyyyy]

I do enjoy a good canceled case. Thanks Ozempic

[@Boodieman72]

If a patient comes in through the ER there isn't an option to not eat, so there must be a way to have anesthesia on a full stomach. No one should be taking drugs to lose weight.

[@saxdemonsjs571]

Well, from what I understand if a patient comes to the ER and needs emergency surgery, their life is at risk anyways. So you either operate and risk aspiration or you don't operate and they die. Thats why they take the risk with emergency surgery

[@MaxFeinsteinMD]

There is an option, which is to proceed with anesthesia. It just entails a higher risk of aspiration. So it needs to be a risk versus benefit discussion.

[@Boodieman72]

@@MaxFeinsteinMD My late brother was a type 1 diabetic so going without food wasn't an option for him, as far as I know. What would the protocol be in that situation, IV glucose? Thank you for making these videos Max.

[@208_treasure6]

These aren't weight loss drugs. They are diabetic drugs.

[@MaxFeinsteinMD]

Wegovy is FDA approved for weight loss.