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.
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