Semaglutide is a long-acting glucagon-like peptide-1 receptor agonist known to delay gastric emptying. Despite a growing body of evidence, its peri-operative safety profile remains uncertain, particularly with regard to the risk of increased residual gastric content and aspiration of gastric contents during anaesthesia. We hypothesised that semaglutide interruption of ≤ 10 days before elective surgical procedures is insufficient to reduce or normalise the residual gastric content, despite fasting intervals that comply with current guidelines.
In this prospective observational study, we recruited patients who received pre-operative once-weekly subcutaneous semaglutide within 10 days of the procedure (semaglutide group) and control patients who had not been exposed to semaglutide (non-semaglutide group). On the day of surgery, all patients underwent pre-operative point-of-care gastric ultrasound to evaluate their residual gastric content. Increased residual gastric content was defined as any solid content or > 1.5 ml.kg-1 of clear fluids as assessed by gastric ultrasound.
We recruited 220 patients, 107 in the semaglutide group and 113 in the non-semaglutide group. Increased residual gastric content was found in 43/107 patients (40%) in the semaglutide group and 3/113 (3%) in the non-semaglutide group (p < 0.001). In propensity-weighted analysis, semaglutide use (OR 36.97, 95%CI 16.54–99.32), age (OR 0.95, 95%CI 0.93–0.98) and male sex (OR 2.28, 95%CI 1.29–4.06) were significantly associated with increased residual gastric content. There were no cases of pulmonary aspiration of gastric contents.
Pre-operative semaglutide use within 10 days of elective surgical procedures was independently associated with increased risk of residual gastric content on pre-operative gastric ultrasound assessment.
We commend Griffiths et al. [1] for their work on managing intrathecal catheters after inadvertent dural puncture in obstetric patients. These evidence-based recommendations complement and enhance previous guidelines published in Anaesthesia [2]. The recommendation for early removal of intrathecal catheters is particularly noteworthy, as it corresponds with recent findings in the field. We previously recommended leaving the intrathecal catheter for 24 h, but subsequent research has indeed shown no benefit in prolonged catheterisation. In a recent study of 550 cases of accidental dural puncture, we found no advantage in leaving the intrathecal catheter in for 24 h postpartum (postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40) [3]. This aligns well with the Obstetric Anaesthetists' Association current recommendation and supports the trend towards earlier catheter removal. Injecting intrathecal saline through the catheter was associated with decreased odds of developing postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and reduced need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001) [3]. Moreover, there is some evidence suggesting that a combined approach, such as prophylactic cosyntropin administration with intrathecal 0.9% saline injection, may offer additional benefits in managing postdural puncture headache [4]. This area warrants further investigation and consideration in future updates.
We agree with the authors on the importance of long-term follow-up. However, we suggest extending the follow-up period and explicitly including screening for chronic pain and postpartum depression. Recent studies have shown that women who experience accidental dural puncture are at increased risk of both these complications [5].
We hope that ongoing research in intrathecal 0.9% saline injection, prophylactic treatments and the importance of extended follow-up with screening for chronic pain and postpartum depression can further optimise care for these patients.
Iron deficiency is present in up to 75% of patients presenting for colorectal cancer surgery. It is unclear whether iron deficiency without anaemia is associated with worse postoperative outcomes. We hypothesised that, in adults without anaemia undergoing surgery for colorectal cancer, iron deficiency would be associated with worse postoperative outcomes relative to an iron-replete state.
We performed a prospective, observational study, recruiting adults (aged ≥ 18 y) without anaemia who were undergoing surgery for colorectal cancer in 16 hospitals across Australia and Aotearoa/New Zealand. Anaemia was defined as a haemoglobin concentration < 130 g.l-1 for men and < 120 g.l-1 for women. Iron deficiency was defined primarily as transferrin saturation < 20%. The primary endpoint was days alive and at home on postoperative day 90. The primary endpoint analysis was adjusted for surgical risk based on recruiting institution; sex; Charlson comorbidity index; CR-POSSUM score; surgical approach; and requirement for neoadjuvant therapy.
Of 420 patients, 170 were iron deficient and 250 were iron replete. The median (IQR [range]) days alive and at home in the iron-deficient group was 84.0 (80.7–85.9 [0–88.2]) days and in the iron-replete group was 83.1 (78.7–85.1 [0–88.9]) days. The unadjusted difference in medians between groups was 0.9 (95%CI 0–1.8, p = 0.047) days and the adjusted difference was 0.9 (95%CI 0–1.80, p = 0.042) days, favouring the iron-deficient group.
In adult patients without anaemia undergoing surgery for colorectal cancer, iron deficiency defined by transferrin saturation < 20% was not associated with worse patient outcomes and appeared to be associated with more days alive and at home on postoperative day 90.
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