ANAESTHESIA SPECIALISTS HYPNOS Minden Surgical Centre P A T I E N T INFORMATION
PERIOPERATIVE CARE Coordinated care before, during, and after surgery Australia and New Zealand are two of the safest places in the world to have an operation under anaesthesia. The chances of dying due to complications during surgery are extremely low (1:100,000 cases). But complications arising after surgery are the third leading cause of death in the developed world. If you’re very old or very sick, a bit of extra care before and after your operation ensures you’re ready for surgery in the first place and have the best chance of a good recovery once the operation is over. We call this the perioperative care approach. It involves a dedicated team of healthcare professionals specialising in different areas of medicine working together to: • Improve your experience and outcomes before, during, and after surgery. • Reduce the risk of postoperative complications. • Reduce the number of days you spend in hospital. • Minimise the chance of you being readmitted to hospital after surgery. The perioperative care approach is gradually being established in hospitals and healthcare systems around Australia and New Zealand. As with elsewhere in the world, anaesthetists are taking the lead, due to their specialist understanding of the factors affecting patients’ suitability for surgery and recovery. The Australian and New Zealand College of Anaesthetists (ANZCA) offers a unique qualification in perioperative medicine designed to increase the number of specialist doctors working in this field. With thanks to Dr Edith Waugh at the Royal Darwin Hospital, Aboriginal Kidney Health Mentors and members of the Renal Advocacy Advisory Committee (RAAC) of the Northern Territory whose work inspired the creation of this version of the Perioperative Care Framework diagram for patients.
As a leading authority on anaesthesia in Australia and New Zealand, ANZCA provides accessible, evidence-based information designed to help you make informed decisions. Scan the QR code to visit our website anzca.edu.au. This information is a guide only and should not replace information supplied by your anaesthetist. PATIENT INFORMATION What is anaesthesia? Most people will need the care of an anaesthetist at some stage in their lives. But it’s one of those things we don’t really think about until we need it. Australia and New Zealand are two of the safest places in the world for anaesthesia. All anaesthetists are highly trained. Relieving pain and providing comfort is central to the practice of anaesthesia, which involves administering medications to minimise unpleasant sensations, including pain. This allows doctors to perform medical and surgical procedures without causing you undue distress or discomfort. Is anaesthesia safe? Anaesthesia is one of the greatest discoveries of modern medicine. Many of today’s operations, especially for the very young, very old or very ill wouldn’t be possible without it. All anaesthetists are highly trained. After finishing medical school and working for at least two years as junior doctors, specialist anaesthetists complete at least five years of training to become qualified fellows of the Australian and New Zealand College of Anaesthetists. What are the three main types of anaesthesia? There are several types of anaesthesia that may be used individually or in combination, depending on the surgery. With the possible exception of emergency situations, your anaesthetist will consult with you and your surgeon in deciding the safest and most appropriate type of anaesthesia for your situation. Sedation helps you to feel relaxed, more comfortable and to have little or no memory of the procedure. Regional anaesthesia is used, where feasible, to numb the operative area, allowing you to be fully aware but not in pain. Anaesthetic procedures like epidurals numb a specific area of the body. General anaesthesia produces unconsciousness, and stops you from being aware or feeling pain during your procedure. It may be associated with changes in breathing and circulation. When will I need to speak to my anaesthetist? Your anaesthetist will generally become involved in your care as part of the surgical team before your surgery to assess your medical condition and plan your anaesthesia. They’ll closely monitor your health and wellbeing throughout the procedure and help to ensure a smooth and comfortable recovery. Am I asleep during general anaesthesia? Being under general anaesthesia is different from sleeping. You’re in a carefully controlled state of unconsciousness. What if the anaesthetic doesn’t work? Your anaesthetist will talk to you before your operation about your general health to get a better idea of how likely you are to react to various anaesthetic drugs, the dosage they need to give you and any likely side effects. This will enable your anaesthetist to ensure that it does work and they will be closely monitoring you throughout the procedure.
PATIENT INFORMATION Preparing for your operation As a leading authority on anaesthesia in Australia and New Zealand, ANZCA provides accessible, evidence-based information designed to help you make informed decisions. Scan the QR code to visit our website anzca.edu.au. This information is a guide only and should not replace information supplied by your anaesthetist. Having surgery under anaesthesia can be a bit daunting, especially if it’s your first time. But there are a few simple things you can do to get yourself better prepared for your surgery. A little bit of preparation before your anaesthesia can make a huge difference. Firstly, remember you’re in very safe hands. All anaesthetists in Australia and New Zealand are highly trained and accredited doctors. They’ll be with you and closely monitoring you throughout your operation, with your safety as the priority. What does my anaesthetist need to know before my operation? Every patient – and every operation – is different, which means your response to anaesthesia will be too. So, there are a few things your anaesthetist will need to know about you before your operation: • Your general health and fitness. • Any existing health conditions or allergies. • Any medication you’re taking. • Any issues you or your family members may have had with anaesthesia in the past. • And anything else you do that might affect your anaesthesia. The consultation with your anaesthetist prior to surgery is a good time for you to ask any questions. If you’re a smoker, your anaesthetist will probably ask you to give smoking a break – even quitting for a short period is helpful. The better you look after your body before your operation, the quicker you will recover. Can I eat before my operation? Your anaesthetist will give you specific instructions on when to stop eating and drinking before your surgery, because having undigested food or any liquid containing particles in your system can cause serious complications. What happens before my operation? Before you go into the operating theatre, your anaesthetist will generally have another conversation with you to check on your comfort and discuss any last-minute questions. What happens after my operation? Your anaesthetist will be with you as the anaesthesia wears off to make sure you’re okay and feeling as comfortable as possible. Can I drive after I’ve had anaesthesia? You’ll need to arrange for a family member or friend to pick you up after your surgery, because it won’t be safe for you to drive for at least 24 hours, as your reflexes take time to get back to normal.
Printed from: Anaesthesia & Sedation for Breastfeeding Parents https://www.breastfeeding-anaesthesia.info/ 1 ANAESTHESIA & SEDATION FOR BREASTFEEDING PARENTS PATIENT INFORMATION Summary It is quite common that people will need surgery at some point while they are breastfeeding. As well as the usual worries about coming for an operation or procedure, parents often feel concerned about the safety of continuing to breastfeed afterwards. Most people can continue to breastfeed following sedation or anaesthesia. "Pumping and Dumping" (or expressing and disposing of the expressed breast milk) is hardly ever required. Please let the healthcare providers looking after you know that you are breastfeeding so they can discuss this with you and support you to do this around the time of your surgery. If you have any concerns about your health or the health of your baby let the team caring for you know. This website is not a substitute for individualised health care advice. Types of Anaesthesia Sedation: medicine is given (often via an intravenous cannula or "drip") to make you comfortable during a procedure. For example - colonoscopy/gastroscopy (camera tests of the gut), dental procedures, minor surgery under local anaesthesia General Anaesthesia (GA): medicine is given via a cannula to make you unconscious for an operation. For example - abscess surgery, appendicectomy (removal of appendix), cholecystectomy (removal of gallbladder). Regional Anaesthesia: using local anaesthetic (LA) to block a nerve or group of nerves to allow surgery to occur without pain. For example - spinal anaesthesia, epidural, arm block. Often a regional can be done without any sedating medications which allows you to return to eating, drinking and breastfeeding as quickly as possible after the surgery. Before the Procedure • Let your surgeon/proceduralist and anaesthetist know that you are breastfeeding
Printed from: Anaesthesia & Sedation for Breastfeeding Parents https://www.breastfeeding-anaesthesia.info/ 2 • If possible, you can consider delaying non-urgent surgery until after you have finished breastfeeding (although this is usually not possible or required) • Keep well hydrated - continue eating and drinking until the time you have been told do stop. If you are waiting a long time for your procedure while nil by mouth (not eating/drinking) ask if you have some intravenous fluids or continue drinking clear fluids. • Breastfeed as close as possible to the start of your procedure or surgery • If you are having a long operation or major surgery it may be useful to express and store milk prior to the day of surgery so that someone can feed your baby while you are in surgery. You may also find it helpful to be seen by a lactation consultant if possible. • If your baby was born prematurely or has a history of apnoeas (pauses in breathing) discuss this with your doctor - expressing before surgery for these babies may be useful. • Ensure someone is available to care for your baby or child while you are in surgery and to help after the procedure. • Some surgeries may be able to be done under regional anaesthesia (see above) - discuss this with your anaesthetist. After the Procedure • The general rule is that: if you are awake enough to hold your baby you are awake enough to breastfeed • Try and have someone bring your baby to you as soon as possible after the procedure so you can breastfeed them once you are awake. If this is not possible you may wish to pump or express once awake. • A responsible adult should stay with you during this time to help ensure the safety of your baby or child. This is especially important if you are needing large doses of pain relief after your surgery. • If you have a premature baby or baby with a history of apnoeas (as above) you may consider expressing and giving the milk when the baby is older or mixing the milk with milk expressed before surgery to reduce the amount of sedating medications in it. • Care should be taken with co-sleeping following sedation and anaesthesia as you may not wake as usual in the night. For brief procedures not requiring much pain relief afterwards it is recommended that you avoid co-sleeping for the first night after the procedure. For longer operations or surgery requiring large doses of pain relief you should discuss this with the doctors caring for you. Medications & Breastfeeding Please note, this is general advice for most patients - for any specific information please discuss with the doctors caring for you.
Printed from: Anaesthesia & Sedation for Breastfeeding Parents https://www.breastfeeding-anaesthesia.info/ 3 Analgesics (Pain Relievers): Paracetamol - safe with breastfeeding Non-steroidal anti-inflammatory drugs (NSAIDs) e.g. ibuprofen (Nurofen), diclofenac (Voltaren) - safe with breastfeeding Opioids (e.g. morphine, fentanyl, oxycodone) - generally safe at lowest dose that provides good pain relief for shortest amount of time possible. However it is recommended that codeine is avoided in breastfeeding as some babies may be more sensitive to it. Sometimes opioids are given as part of a regional anaesthetic (spinal or epidural) – only very very small amounts end up in breastmilk so it is safe to continue breastfeeding. Tramadol – safety for breastfeeding mothers has been discussed recently, appears to be safe. Ketamine - low doses for pain likely to be safe for breastfeeding Gabapentin - likely safe for short term use Pregabalin - there is limited information about the use in breastfeeding mothers, discuss with your doctor Anaesthetic Medications: Local Anaesthetics (LA) - safe with breastfeeding Propofol - safe with breastfeeding Midazolam - safe with breastfeeding Volatile (Gas) Anaesthetics - safe with breastfeeding Neuromuscular Blockers (Muscle Relaxants) and Reversal - safe with breastfeeding Antiemetics (Anti-Nausea Medications): Safe with breastfeeding although some MAY reduce breastmilk supply (e.g. promethazine, scopolamine). Other Medications:
Printed from: Anaesthesia & Sedation for Breastfeeding Parents https://www.breastfeeding-anaesthesia.info/ 4 Antibiotics - most are safe in breastfeeding although some may cause gut symptoms in breastfeeding babies. It is recommended that some antibiotics are avoided e.g. doxycyline, ciprofloxacin, and high doses of metronidazole. Radiological contrast - almost all safe in expressing except Technitium containing contrast which requires breastmilk to be expressed and disposed of for 12 hours. Frequently Asked Questions 1. I am breastfeeding my 5 month old daughter and am due to have a colonoscopy next week with midazolam and fentanyl sedation. I have been told I need to "pump and dump" for 24 hours afterwards. Is this correct? This is very unlikely to be required. Unless your baby has significant health issues you can continue to breastfeed as usual following the procedure. Please read the above advice and make sure you stay well hydrated as the bowel preparation required can cause dehydration which may affect your milk supply. 2. I am due to have my gallbladder removed next week and I am expressing breastmilk for my 2 week old child who was born 6 weeks early and had some pauses in her breathing in the first few days in the newborn unit. What should I do? Please discuss this with the doctors caring for your baby. The general advice is to feed your baby or express as close to the start of your operation as possible. After the procedure you can continue to express and either store that milk for when your baby is older or mix it with milk you have expressed prior to the operation. 3. I am due to have a major operation next week and am breastfeeding my one year old son. I would like to continue feeding if I can. Please can you help? Please let the doctors caring for you know that you are currently breastfeeding. You may wish to express some milk in advance if possible to have some stored for your son if required. You will most likely be able to continue breastfeeding after the operation but discuss this with your healthcare team. 4. I am due to have an MRI this week and am breastfeeding my 3 month old. I've been told I need to express and dispose of the milk for 24 hours afterwards. Is this required? No, MRI contrast does not require you to dispose of your breastmilk. You can continue to breastfeed as usual. 5. I need a minor procedure done on my foot. Even though I know it's safe to breastfeed after general anaesthesia I'm wondering if there are any other options? You may be able to have your procedure done under regional anaesthesia (blocking nerves). Please discuss this with the anaesthetist who will be caring for you.
Types of anaesthesia There are several types of anaesthesia that may be used individually or in combination, depending on the surgery. For some types of surgery, several options are available. Except in emergency situations, specialist anaesthetists will consult with the patient and the surgeon to decide on the safest and most appropriate type of anaesthesia for the clinical situation. The anaesthetist will consider several factors when planning a patient’s anaesthesia including: • Past experience with surgery. • Health and physical condition. • Reactions or allergies to medicines. • Risks of each type of anaesthesia. • Preferences of your surgical team. • Your preferences. Local Anaesthesia Local anaesthesia involves injecting local anaesthetic into the tissues near the surgical site. Local anaesthesia may be used alone or in combination with sedation or general anaesthesia. This depends on the size of the surgery and the time it will take, and the preferences of the patient. Local anaesthesia is usually used for minor surgery, such as toenail repair, skin lesion or a cut to remove something. It may not be used if the patient has an infection. Regional anaesthesia Regional anaesthesia involves injecting local anaesthetic around major nerve bundles supplying body areas, such as the thigh, ankle, forearm, hand, shoulder or abdomen. It may be used on its own or with general anaesthesia. Regional anaesthesia is sometimes performed using a nervelocating device such as a nerve stimulator, or using ultrasound, to accurately locate the nerves. Once local anaesthetic is injected, patients may experience numbness and tingling and it may become difficult or impossible to move that part of the body. The duration of the anaesthesia depends on which local anaesthetic is used, the region into which it is injected and whether it is maintained by continual doses or repeated injections. Numbness can last several hours but may last several days. Generally, the “heaviness” wears off within a few hours but the numbness and tingling persists much longer. As the local anaesthetic effect wears off, numbness will diminish and the surgical pain may return, in which case your doctor will prescribe pain relief. Sedation Conscious sedation reduces the patient’s level of consciousness but allows them to respond to verbal commands or light touch so that a specialist can perform a procedure. A variety of medications and techniques are used for procedural sedation and/or pain relief. Common medications include benzodiazepines, such as midazolam, which act on the brain and the nervous system to cause sedation, and opioids, such as fentanyl, which decrease the patient’s perception of pain to provide pain relief.
These medications may be administered orally but are usually administered into a vein. Deep levels of sedation, where patients lose consciousness and respond only to painful touch, may be associated with the patient having difficulty breathing normally and their heart function may be affected. The anaesthetist is trained to manage these situations. General anaesthesia General anaesthesia involves putting a patient into a medication-induced state of carefully controlled unconsciousness. When the anaesthetic is deep enough, the patient will not respond to pain. It also includes changes in breathing and circulation. During a general anaesthetic, the anaesthetist is constantly monitoring the patient to manage the airway, blood circulation and general responses. This information is a guide and should not replace information supplied by your anaesthetist. If you have any questions about your anaesthesia, please speak with your treating specialist.
Anaesthesia for endoscopy Endoscopy procedures, which include gastroscopy and colonoscopy, are frequently performed as day-stay cases. Gastroscopy is a procedure where a flexible tube with a camera at its tip is inserted via the mouth passing through the oesophagus into the stomach and first part of the small bowel. It is used to investigate and treat symptoms such as difficulty swallowing, heartburn (gastroesophageal reflux disease), and oesophageal and stomach tumours. Colonoscopy is a procedure where a long flexible tube with a camera at its tip is inserted via the rectum to allow a doctor to see the large bowel. It is used to investigate conditions affecting the large intestine. Many conditions do not have symptoms at the early stages and endoscopic treatment usually involves removing polyps or foreign objects. In most cases, endoscopy patients are given deep “procedural sedation”, which allows the specialist to perform the procedure and aims to ensure patient safety and comfort. An anaesthetist may use a variety of medications and techniques to achieve procedural sedation and/or pain relief. The most common medications used that are injected into a vein are benzodiazepines (which act on the brain and the nervous system) such as midazolam for sedation, and opioids (which decrease the patient’s perception of pain), such as fentanyl, for pain relief. During deep sedation, where patients lose consciousness and respond only to painful touch, patients may have difficulty with breathing normally and their heart function may be affected. The anaesthetist is trained to avoid these situations. Before the procedure It is important that you speak to your doctor about when you should stop eating and drinking before your anaesthetic. The anaesthetist will also need information such as: • Any recent coughs, colds or fevers. • Any previous anaesthetics or family problems with anaesthesia. • Abnormal reactions or allergies to drugs. • Any history of asthma, bronchitis, heart problems or other medical problems. • Any medications you may be taking. This information is a guide and should not replace information supplied by your anaesthetist. If you have any questions about your anaesthesia, please speak with your treating specialist.
Anaesthesia for joint replacement surgery Joint replacement surgery is a common and effective procedure for relieving disability due to severe joint pain and loss of function. The surgery involves removing a damaged joint or part of it – such as a knee, hip or shoulder – and putting in a new one. An orthopaedic surgeon is usually the person who does joint replacement surgery, and may either replace the damaged joint with a prosthesis, or replace or fix only the damaged parts. The anaesthetist will consider several factors when planning your anaesthesia, including: • Past experience with surgery. • Health and physical condition. • Reactions or allergies to medicines. • Risks of each type of anaesthesia. • Preferences of your surgical team. • Your preferences. Regional anaesthesia is the most common form of anaesthesia used during joint-replacement surgery because it aims to provide optimal pain relief while minimising side effects such as sedation, post- operative nausea and vomiting, and leg weakness. It may be used on its own or combined with sedation or general anaesthesia. Regional anaesthesia numbs the part of the body where the surgery will happen. It involves the injection of local anaesthetic around major nerve bundles supplying body areas, such as the thigh, ankle, forearm, hand, shoulder or abdomen. This is sometimes done using a nerve-locating device, such as a nerve stimulator, or ultrasound, so that the anaesthetic can be delivered with greater accuracy. Once local anaesthetic is injected, you may experience numbness and tingling in the area supplied by the nerves and it may become difficult or impossible to move that part of the body. Before the operation It is important that you speak to your doctor about when you should stop eating and drinking before your anaesthetic. The anaesthetist will also need information such as: • Any recent coughs, colds or fevers. • Any previous anaesthetics or family problems with anaesthesia. • Abnormal reactions or allergies to drugs. • Any history of asthma, bronchitis, heart problems or other medical problems. • Any medications you may be taking. What to expect Each surgery is different. How long an operation takes depends on how badly the joint is damaged and how the surgery is done. The duration of the anaesthesia depends on which anaesthetic is
used, the region into which it is injected, and whether it is maintained by continual doses or repeated injections. After surgery, you will be moved to a recovery room for a period of time until you are ready to be returned to the ward. Typically, numbness can last several hours but may last several days. Generally, the “heaviness” wears off within a few hours but the numbness and tingling may persist much longer. As the local anaesthetic effect wears off, numbness will diminish and surgical pain may return, in which case your doctor will prescribe alternative methods of pain relief, including injections or tablets. Because osteoarthritis is often found in hips and knees, and patients undergoing hip or knee replacements are often elderly, there may be complications. Many joint-replacement patients have other medical conditions – diagnosed and undiagnosed – such as high blood pressure and heart problems, which require assessment and investigation. Most patients undergoing joint replacement tend to accept the risks involved because of the potential improvement in their quality of life. This information is a guide and should not replace information supplied by your anaesthetist. If you have any questions about your anaesthesia, please speak with your treating specialist.
FACT SHEET Have you had axillary lymph nodes removed during breast surgery? Background Patients who have undergone this surgery have traditionally been advised to avoid having the arm on the affected side used for medical procedures because it was thought this might contribute to the occurrence of swelling known as lymphoedema. This is a complication that may arise following axillary surgery, including sentinel lymph node biopsy, targeted axillary dissection, and axillary clearance. However, clinical evidence shows this is not the case and that the arm on the affected side can usually be safely used for medical procedures. In fact, in many circumstances, using the arm on the affected side can be better for patient comfort and safety, because: • Relying solely on the blood vessels in unaffected arms can result in damage through overuse, and cause discomfort. • While using lower limbs for the procedures listed below may be an option, this can result in a less accurate measurement of blood pressure. As the leading authority on anaesthesia in Australia and New Zealand, ANZCA provides accessible, evidence-based information designed to help you make informed decisions. Scan the QR code to visit our website anzca.edu.au. This information is a guide only and should not replace information supplied by your anaesthetist. ANZCA acknowledges the contribution of: Associate Professor Victoria Eley – PhD, FANZCA (Expert group lead); Professor Christobel Saunders, AO, FRCS, FRACS; Associate Professor Pierre Bradley, FANZCA; Ms Joanne Lovelock, Breast Care Nurse Clinical Lead TAS VIC; Ms Rebecca James, Consumer representative; and Dr Peter Roessler, FANZCA, Director of Professional Affairs (Professional Documents). What procedures does this advice cover? It applies to common medical procedures performed by anaesthetists and other health care professionals on patients’ arms, including: • Taking blood. • Administering and delivering medication via an intravenous (IV) drip. • Performing anaesthesia monitoring such as invasive and non-invasive blood pressure monitoring. I don’t have lymphoedema (swelling) in my arm. Is it safe to use for medical procedures? If you have had your axillary lymph nodes removed and do not have lymphoedema, the arm(s) may be safely used for the medical procedures listed above. Your health care professional will discuss this with you. I have lymphoedema in my arm. Is it safe to use for medical procedures? If you have pre-existing swelling, your arm can still be used. Any decisions in this regard will be guided by your healthcare professional, who will discuss any other options and advise on the most suitable one for you. Where can I find more details? Appendix A in ANZCA’s professional document on anaesthesia monitoring, PG18 (A): Guideline on monitoring during anaesthesia, includes more detail about the safety and comfort of using arms affected by axillary surgery.
1 April 2025 Clinical Practice Recommendations regarding patients taking GLP-1 receptor agonists and dual GLP-1/GIP receptor co-agonists prior to anaesthesia or sedation for surgical and endoscopic procedures. A consensus clinical practice recommendation endorsed by the Australian Diabetes Society (ADS), National Association of Clinical Obesity Services (NACOS), Gastroenterological Society of Australia (GESA) and Australian and New Zealand College of Anaesthetists (ANZCA). Purpose of this document To provide recommendations for managing patients taking glucagon-like peptide-1 receptor agonists (GLP-1RAs) and dual GLP-1/glucose-dependent insulinotrophic peptide receptor co-agonists (GLP-1/GIPRAs) prior to anaesthesia or sedation for surgical and endoscopic procedures. Scope This advice applies to all practitioners providing moderate to deep procedural sedation or anaesthesia. Although focused on surgical and endoscopic procedures, the principles should apply to any procedures requiring anaesthesia or sedation. Background In response to case reports and large case series of retained gastric contents and pulmonary aspiration during sedation for endoscopic procedures or general anaesthesia in people with diabetes and/or obesity treated with GLP-1RAs or GLP-1/ GIPRAs, a clinical practice recommendation regarding the periprocedural use of GLP-1RAs and GLP-1/GIPRAs has been co-authored and updated by representatives from ADS, NACOS, GESA and ANZCA. The below represents a consensus based on review of currently available evidence and expert opinion. Although the current level of evidence remains limited, new data and other multidisciplinary clinical guidelines [1, 2] have been considered. This document was written to mitigate the risk of pulmonary aspiration with the periprocedural use of GLP-1RAs and GLP-1/GIPRAs which, although rare, is high-risk and potentially fatal. Recommendations relating to GLP-1RAs and GLP-1/GIPRAs and sedation or anaesthesia: • All patients should be asked about the use of GLP-1RAs and GLP-1/GIPRAs prior to anaesthesia or sedation for surgical and endoscopic procedures and be involved in discussion and planning regarding the risk of aspiration. • Elective preprocedural cessation of GLP-1RAs and GLP-1/GIPRAs is not recommended, and risks hyperglycaemia in people with diabetes and may compromise weight control where patients are taking GLP-1RAs and GLP-1/GIPRAs for this indication. • Patients should be asked about the use of other medications and medical conditions which may exacerbate gastrointestinal symptoms and delay gastric emptying, such as, but not limited to bowel dysmotility, gastroparesis, and Parkinson’s disease. • Preprocedural diet modification with 24-hour clear fluid diet, followed by standard 6-hour fasting, should be recommended for all patients receiving GLP-1 RAs and GLP-1/GIPRAs. • Risk mitigation options should be undertaken for those who have not withheld solids for 24 hours. These include detection of residual gastric contents, prokinetic agents, modification of anaesthesia, or deferral of procedure (see figure and explanatory notes).
April 2025 Pa ent rece Yes Clear fluid diet for 24 hours prior to procedure, with 6-hour fast pre-procedure Yes Proceed with usual airway precau ons Proceed w Bedside gastric ultrasound to determine gastric contents OR Minimally sedated gastroscopy with ultrathin 5mm gastroscope (depending on availability) 4 Proceed with usual airway precau ons Proceed as per x local protocols for unfasted pa ents 6 Defer procedure 7 Intrave (in absence of procedure to a Assessment strongly suggests empty stomach Retained gastric contents present. Management op ons incude: Figure: Clinical practice recommendations for patients taking GLP-1 receptor agonists and dual GLP-1 and GIP receptor co-agonists prior to anaesthesia or sedation for surgical and endoscopic procedures. Numbers relate to the explanatory notes following. IF YOU ARE NOT SEEING THIS PAGE AND THE NEXT AS A DOUBLE PAGE SPREAD, CLICK HERE
2 eiving GLP-1RA or GLP-1/GIP RA? 1 No 2 These guidelines do not apply. Proceed with usual airway precau ons No with any of the following risk mi ga on strategies (not listed in order of preference) 3 Intravenous erythromycin (in absence of contraindica ons) prior to procedure to accelerate gastric emptying 5 Proceed as per x local protocols for unfasted pa ents 6 Defer procedure 7 Proceed with usual airway precau ons enous erythromycin contraindica ons) prior to accelerate gastric emptying 5 Wait 90 – 120 minutes Bedside gastric ultrasound to determine gastric contents OR Minimally sedated gastroscopy with ultrathin 5mm gastroscope (depending on availability) Assessment strongly suggests empty stomach 4 IF YOU ARE NOT SEEING THIS PAGE AND THE PREVIOUS AS A DOUBLE PAGE SPREAD, CLICK HERE
3 April 2025 Explanatory notes 1. Patients should be asked about the use of GLP-1RA and GLP-1/GIPRAs prior to undergoing anaesthesia or sedation. The patient, prescribing clinician, proceduralist or surgeon and the anaesthetist should be involved with discussions regarding planning for the procedure, including risks and benefits of withholding therapy and those of alternative and mitigating strategies [2]. a. Elective preprocedural cessation of GLP-1RA and GLP-1/GIPRAs is not recommended. Currently, there are insufficient data to support the cessation of GLP-1RA and GLP-1/GIPRAs prior to anaesthesia [2]. Omission of longer-acting GLP-1RA and GLP-1/GIPRAs for 1-2 weeks is unlikely to alter gastric emptying. Omission for an extended duration may delay urgent surgery or lead to poor glycaemic control at the time of surgery with consequent risks of increased morbidity, length of stay and potentially further deceleration of gastric emptying resulting from hyperglycaemia. Substitution of a different class of glucose-lowering drug for several weeks is often very challenging. Omission of therapy for prolonged periods may compromise weight control where patients are taking GLP1RAs and GLP-1/GIPRAs for this indication. It is also recommended that GLP-1RAs with a shorter half-life (i.e. liraglutide) be continued. In individual circumstances, withholding liraglutide for 3 to 4 days may be considered, however, this may have implications for glycaemic control and weight management. There is no current evidence to support any added safety benefits of this practice. The duration of inhibition of gastric emptying from longer acting GLP-1RA and GLP-1/GIPRAs is unknown and may potentially be several weeks. It has been widely assumed that longer-acting GLP-1RAs do not slow gastric emptying with sustained administration because of tachyphylaxis. This assumption is not supported by existing evidence. The three longer-acting GLP-1RAs that have been assessed using scintigraphy, the ‘gold-standard’ method for quantifying gastric emptying - liraglutide [3-5], exenatide QW [6] and semaglutide sc (1.0 mg/wk) [7] – have been shown to slow gastric emptying with sustained administration of 8 – 16 weeks duration. Further studies, using appropriate methods, to characterise the effect of long-term administration of longer-acting GLP-1RAs and GLP-1/GIPRAs on gastric emptying are a priority. b. Absence of symptoms is an unreliable indicator of gastric emptying The relationship between upper gastrointestinal symptoms (nausea and vomiting) and slowing of gastric emptying by GLP-1RAs is weak. The majority of studies that have evaluated the relationship between the effects of GLP-1RAs on gastric emptying and gastrointestinal symptoms in health, obesity, or T2D found no or low correlations [8-10]. A recent retrospective study of 404 patients undergoing elective oesophagogastroduodenoscopy found an association of semaglutide use with both the presence of preoperative digestive symptoms (nausea/vomiting, dyspepsia, abdominal distension) and residual gastric content, however numbers were small [11]. Based on these limited data, the presence of gastrointestinal side effects is not a reliable indicator of the degree of slowing of gastric emptying. c. Incidental interruption of therapy Given possible supply issues, GLP-1RA and GLP-1/GIPRA therapy may have been interrupted due to lack of availability. If GLP-1RA and GLP-1/GIPRA therapy has been interrupted for 4 elimination half-lives or more (see Table 1) it may be assumed that the effect of the medication on gastric emptying is no longer present. Table 1: GLP-1 RAs and Dual GLP-1 and GIP co-agonists registered for use in Australia Agent Receptor agonism Elimination half-life Administration schedule Trade name Liraglutide GLP-1 12.6 – 14.3 hours Once daily Victoza (up to 1.8 mg) Saxenda (up to 3.0 mg) Dulaglutide GLP-1 4.7 – 5.5 days Once weekly Trulicity Semaglutide GLP-1 5.7 – 6.7 days Once weekly Ozempic (up to 1 mg) Wegovy (up to 2.4 mg) Tirzepatide GLP-1 & GIP 4.2 – 6.1 days Once weekly Mounjaro
4 April 2025 2. A 24-hour clear liquid diet may help empty gastric contents. Two recent systematic reviews and meta-analyses found an increased risk of retained gastric contents at oesophagogastroduodenoscopy in continuous GLP-1RA users compared with controls. In contrast, the rate of retained gastric contents in GLP-1RA users undergoing both oesophagogastroduodenoscopy and colonoscopy was significantly reduced [12, 13]. This suggests that a 24-hour clear liquid diet prior to GI endoscopy may mitigate the risk of retained gastric contents without discontinuing GLP-1RA therapy. The composition of what constitutes a liquid diet varies amongst centres and is also the basis of ongoing studies. Although conservative, a ‘clear liquids’ diet, as advised in preoperative fasting guidelines, is considered the most appropriate option at this time. Local practice recommendations for clear liquids diet form the best guide at this stage. The ADS-ANZCA Perioperative Diabetes and Hyperglycaemia Guidelines (Adults) provides further information and guidance regarding the management of diabetes medications during this period. Prior to the procedure, recommended fasting guidelines should be followed from 6 hours (see ANZCA Professional Document PG07 Preanaesthesia consultation Appendix 1). 3. Residual gastric contents are likely in patients taking GLP-1RAs and may increase aspiration risk. Risk mitigation strategies are necessary. A number of case reports and small case series of retained gastric contents at the time of gastroscopy or anaesthesia, in people with diabetes and/or obesity treated with GLP-1 RAs, have been published [11, 14-20]. These reports suggest that GLP-1 RAs pose a threat to periprocedural patients, by increasing the risk of pulmonary aspiration of regurgitated gastric contents. To date, there have been 6 case reports of pulmonary aspiration at the time of endoscopy or anaesthesia in patients treated with GLP-1RAs [11, 16, 19, 20]. A large population-based, retrospective cohort study using a health insurance database (including ~800,000 patients undergoing endoscopy) found a higher incidence of aspiration pneumonia (0.83% vs 0.63%) in GLP-1RA users compared to non-users, associated with a significantly higher risk of aspiration pneumonia (hazard ratio 1.33; 95% confidence interval 1.02–1.74; p=0.036). When subgrouped by endoscopy type, the risk appeared to be associated with upper endoscopy, combined upper and lower endoscopy but not lower endoscopy alone [21]. Retrospective case-control studies of patients undergoing upper gastrointestinal endoscopy have found a 4- to 10-fold increase in the frequency of residual gastric contents with GLP-1RA use compared with controls [11, 15, 22]. Although only anecdotal, case reports found that retained gastric contents were present despite appropriate fasting, of 8 hours for clear fluids to 20 hours for solids [17]. A small prospective observational study of overnight fasted healthy volunteers, 10 of whom were taking semaglutide for weight management and 10 controls who were not taking semaglutide, found residual intragastric solids on ultrasound in 90% of semaglutide-treated volunteers compared with 20% of control volunteers. Limitations of this study are that the dose of semaglutide varied from 0.25 – 0.75 mg weekly and the majority of volunteers taking semaglutide had been treated for less than 4 weeks [23]. In contrast, a retrospective study of 1512 individuals taking GLP-1RAs and undergoing oesophagogastroduodenoscopy found retained gastric contents in 9.4%, primarily consisting of solid residue (78.9%) [24]. The limited data on rates of retained gastric contents in people taking GLP-1 RAs are inconsistent. 4. Detection of residual gastric contents may be indicated in some patients a. Bedside point of care gastric ultrasound can be used to evaluate gastric content and volume to assess perioperative aspiration risk and guide anaesthetic management. Solid, particulate, or thick fluid content, carrying a high aspiration risk, can be detected based on sonographic appearance [25, 26]. ANZCA Professional Document PG47 Perioperative Diagnostic Point of Care Ultrasound and its accompanying Background Paper provides further information and guidance on training requirements for gastric ultrasound. b. Unsedated oesophagogastroduodenoscopy using ultrathin 5–6-mm endoscopes is often well tolerated and allows preservation of airway protective reflexes [27]. Retained gastric contents can be directly visualised. It is important to note that patients may forcibly retch with use of the ultrathin endoscope and oral suction may be required in the event of pharyngeal contamination despite intact protective reflexes. In addition, suction of intra-oesophageal fluid is less efficient with the thinner endoscope.
5 April 2025 5. Prokinetic agents such as Erythromycin may accelerate gastric emptying A single dose of 3mg/kg (up to a dose of 250mg) erythromycin intravenously has been shown to accelerate gastric emptying within 15 minutes [28-35]. In patients with diabetes and gastroparesis a single dose of 200 mg of intravenous erythromycin given 15 minutes prior to starting a meal was able to reduce retained gastric solids from 75% to 22% at 60 minutes and 58% to 6% at 120 minutes compared to baseline [33]. Therefore, we recommend a longer duration of 90-120 minutes between administration of erythromycin and endoscopy when possible. In healthy male subjects receiving a GLP-1 infusion, 200 mg of intravenous erythromycin completely reversed deceleration of gastric emptying whereas other prokinetic drugs including metoclopramide, cisapride and domperidone had no effect [36]. Acute hyperglycaemia has the potential to attenuate the acceleration of gastric emptying by iv erythromycin [37]. Contraindications to the administration of erythromycin should be considered. The effectiveness of intravenous erythromycin to accelerate gastric emptying in individuals on GLP-1RA-based therapy in the periprocedural setting has yet to be evaluated. Repeat gastric ultrasound may be indicated following the administration of erythromycin, but whilst this may be considered prudent, there is currently no evidence to date to require this (therefore indicated as dotted lines on the flowchart (Figure)). 6. Consider management as for unfasted patients if risk mitigation or delay not possible or desirable. If a clear fluid diet has not been followed for 24 hours prior to the procedure, all patients taking GLP-1RA and GLP1/GIPRAs should be considered non-fasted/to have a full stomach. If other risk mitigation strategies are unable to be performed or are unavailable, or concern remains that retained gastric contents are present, anaesthesia should be administered according to local practices for a non-fasted patient. Appropriate anaesthetic techniques should be applied to protect against pulmonary aspiration. Without being prescriptive, consideration should be given to regional anaesthetic techniques with minimal sedation and maintenance of upper airways reflexes, or rapid sequence induction for patients requiring general anaesthesia. 7. Deferral of procedure should be considered if high-risk If after consideration of the risks and benefits, a decision is made with the patient to defer the procedure, arrangements should be made for the patient to follow a clear fluid diet for 24 hours prior to the rescheduled procedure. Consider a longer period of clear fluid diet if retained gastric contents were present despite following mitigation strategies. Authors: Samantha L Hocking1,2,3, David A Scott4,5,6, Matthew L Remedios7, Michael Horowitz8,9, David A Story4, Jerry R Greenfield10,11,12, Alex Boussioutas13,14, Benedict Devereaux7,15, Sof Andrikopoulos16, Jonathan E Shaw17,18, Benjamin L Olesnicky2,19 1. Charles Perkins Centre, University of Sydney, Camperdown, New South Wales 2006, Australia 2. Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales 2006, Australia 3. Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Australia 4. Department of Critical Care, University of Melbourne, Melbourne, Australia 5. Department of Anaesthesia and Acute Pain Medicine, St. Vincent’s Hospital, Melbourne, Australia 6. Director of Professional Affairs (Policy), ANZCA 7. Department of Gastroenterology and Hepatology, The Wesley Hospital, Brisbane, Queensland, Australia. 8. Adelaide Medical School and Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia. 9. Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia 10. Department of Diabetes and Endocrinology, St. Vincent’s Hospital, Sydney, New South Wales, Australia. 11. Clinical Diabetes, Appetite and Metabolism Laboratory, Garvan Institute of Medical Research, Sydney, New South Wales, Australia. 12. School of Clinical Medicine, UNSW Medicine & Health, St Vincent’s Healthcare Clinical Campus, University of New South Wales, Sydney, New South Wales, Australia. 13. Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia. 14. Department of Gastroenterology, The Alfred, Monash University, Melbourne, Victoria, Australia. 15. School of Medicine, The University of Queensland, Brisbane, Queensland, Australia. 16. Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.
6 April 2025 17. Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia. 18. School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Victoria, Australia. 19. Department of Anaesthesia, Pain, and Perioperative Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia. References: 1. Kindel TL, Wang AY, Wadhwa A, Schulman AR, Sharaiha RZ, Kroh M, et al. Multisociety Clinical Practice Guidance for the Safe Use of Glucagon-like Peptide-1 Receptor Agonists in the Perioperative Period. Clin Gastroenterol Hepatol. 2024. doi: 10.1016/j.cgh.2024.10.003. 2. El-Boghdadly K, Dhesi J, Fabb P, Levy N, Lobo DN, McKechnie A, et al. Elective peri-operative management of adults taking glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic peptide agonists and sodium-glucose cotransporter-2 inhibitors: a multidisciplinary consensus statement: A consensus statement from the Association of Anaesthetists, Association of British Clinical Diabetologists, British Obesity and Metabolic Surgery Society, Centre for Perioperative Care, Joint British Diabetes Societies for Inpatient Care, Royal College of Anaesthetists, Society for Obesity and Bariatric Anaesthesia and UK Clinical Pharmacy Association. Anaesthesia. 2025. doi: 10.1111/anae.16541. 3. Maselli D, Atieh J, Clark MM, Eckert D, Taylor A, Carlson P, et al. Effects of liraglutide on gastrointestinal functions and weight in obesity: A randomized clinical and pharmacogenomic trial. Obesity (Silver Spring). 2022;30(8):1608-20. doi: 10.1002/oby.23481. 4. Halawi H, Khemani D, Eckert D, O’Neill J, Kadouh H, Grothe K, et al. Effects of liraglutide on weight, satiation, and gastric functions in obesity: a randomised, placebo-controlled pilot trial. Lancet Gastroenterol Hepatol. 2017;2(12):8909. doi: 10.1016/S2468-1253(17)30285-6. 5. Meier JJ, Rosenstock J, Hincelin-Mery A, Roy-Duval C, Delfolie A, Coester HV, et al. Contrasting Effects of Lixisenatide and Liraglutide on Postprandial Glycemic Control, Gastric Emptying, and Safety Parameters in Patients With Type 2 Diabetes on Optimized Insulin Glargine With or Without Metformin: A Randomized, Open-Label Trial. Diabetes Care. 2015;38(7):1263-73. doi: 10.2337/dc14-1984. 6. Jones KL, Huynh LQ, Hatzinikolas S, Rigda RS, Phillips LK, Pham HT, et al. Exenatide once weekly slows gastric emptying of solids and liquids in healthy, overweight people at steady-state concentrations. Diabetes Obes Metab. 2020;22(5):788-97. doi: 10.1111/dom.13956. 7. Jensterle M, Ferjan S, Lezaic L, Socan A, Goricar K, Zaletel K, et al. Semaglutide delays 4-hour gastric emptying in women with polycystic ovary syndrome and obesity. Diabetes Obes Metab. 2023;25(4):975-84. doi: 10.1111/ dom.14944. 8. Linnebjerg H, Park S, Kothare PA, Trautmann ME, Mace K, Fineman M, et al. Effect of exenatide on gastric emptying and relationship to postprandial glycemia in type 2 diabetes. Regul Pept. 2008;151(1-3):123-9. doi: 10.1016/j. regpep.2008.07.003. 9. Drucker DJ, Buse JB, Taylor K, Kendall DM, Trautmann M, Zhuang D, et al. Exenatide once weekly versus twice daily for the treatment of type 2 diabetes: a randomised, open-label, non-inferiority study. Lancet. 2008;372(9645):1240-50. doi: 10.1016/S0140-6736(08)61206-4. 10. Jalleh RJ, Plummer MP, Marathe CS, Umapathysivam MM, Quast DR, Rayner CK, et al. Clinical Consequences of Delayed Gastric Emptying With GLP-1 Receptor Agonists and Tirzepatide. J Clin Endocrinol Metab. 2024;110(1):1-15. doi: 10.1210/clinem/dgae719. 11. Silveira SQ, da Silva LM, de Campos Vieira Abib A, de Moura DTH, de Moura EGH, Santos LB, et al. Relationship between perioperative semaglutide use and residual gastric content: A retrospective analysis of patients undergoing elective upper endoscopy. J Clin Anesth. 2023;87:111091. doi: 10.1016/j.jclinane.2023.111091. 12. Popov VB, Mohammad; Ahmed, Ali M; Yeoh, Aaron; Dilly, Christen; Papademetriou, Marianna; Pohl, Heiko; Antaki, Fadi; Dominitz,Jason A. Glucagon-Like Peptide-1 Receptor Agonists (GLP-1RA) and Safety of Gastrointestinal (GI) Endoscopic Procedures: A Systematic Review and Meta-Analysis (late-breaking abstract), . ACG 2024 Annual Scientific Meeting Abstracts Philadelphia, PA: American College of Gastroenterology. 13. Baig MU, Piazza A, Lahooti A, Johnson KE, Rangwani S, Gouda Z, et al. Glucagon-like peptide-1 receptor agonist use and the risk of residual gastric content and aspiration in patients undergoing gastrointestinal endoscopy: a systematic review and a meta-analysis. Gastrointest Endosc. 2024. doi: 10.1016/j.gie.2024.12.019.
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