The edition · Anaesthesiology
Four in five adolescents on GLP-1 agonists had solid gastric contents after fasting 13 hours
A gastric ultrasound cohort finds standard fasting does not empty the stomach in this group; the obesity paradox for postoperative delirium turns out to depend entirely on comorbidity burden; and real-time ultrasound nearly doubles first-pass success at lower thoracic epidural puncture.
The edition in brief
A prospective cohort scanned the stomachs of 67 adolescents aged 10 to 18 before surgery. Despite a median fast of 13 hours for solids, 16 of 20 patients (80 per cent) taking a GLP-1 receptor agonist had solids visible on gastric ultrasound, against 17 of 27 (63 per cent) in a group otherwise at risk of delayed emptying and 1 of 20 (5 per cent) healthy controls, a difference that survived propensity adjustment. In 4320 patients aged 65 or over undergoing non-cardiac surgery, postoperative delirium occurred in 14.5 per cent; overweight and class 1 obesity were associated with lower risk overall, but a significant interaction with the Charlson Comorbidity Index showed the protection existed only in patients with low comorbidity burden and disappeared entirely in those with high burden. A meta-analysis of eight randomised trials and 711 patients found laparoscopic-guided transversus abdominis plane block gave lower pain scores than port-site local anaesthetic infiltration at 1, 3, 6 and 24 hours after laparoscopic cholecystectomy, with high GRADE certainty at the earliest timepoints and no difference in rescue analgesia or shoulder pain. In a randomised trial of 64 patients, real-time ultrasound guidance achieved first-pass success at lower thoracic epidural puncture in 81 per cent against 47 per cent with pre-procedural scanning and marking, with no cost in procedure time. The FDA approved a supplement to a generic buprenorphine and naloxone application.
The obesity paradox for postoperative delirium exists only in patients who are otherwise well
Overweight and class 1 obesity were associated with lower postoperative delirium risk only in older patients with a low comorbidity burden, and with no benefit at all once the Charlson index reached 3 - so read body mass index alongside comorbidity, never alone.
A surgeon-placed TAP block beats port-site infiltration in the first hours after cholecystectomy
A laparoscopic-guided transversus abdominis plane block gives better analgesia than port-site infiltration in the first hours after cholecystectomy, with high-certainty evidence at 1 and 3 hours but no reduction in rescue analgesia, shoulder pain or nausea.
FDA clears a supplement to a generic buprenorphine and naloxone application
An FDA supplement to a generic buprenorphine and naloxone application changes nothing clinically, but the patients who take it are a growing perioperative group in whom the drug should be continued, not stopped, with analgesia planned around it.
Watching the needle beats marking the spot at lower thoracic epidural puncture
Real-time ultrasound guidance achieved first-pass success at lower thoracic epidural puncture in 81 per cent of patients against 47 per cent with pre-procedural marking alone, with no additional procedure time.
Stop before you block - and mark the limb yourself
Perform a two-person stop immediately before every block needle goes in, checking consent, the limb mark and the patient - including for the second block on the same list and the same patient.
Standard fasting does not empty the stomach of an adolescent on a GLP-1 agonist
Eighty per cent of adolescents on a GLP-1 receptor agonist had solid gastric contents on ultrasound after a median 13-hour fast, so scan the stomach before induction or treat them as having a full stomach.
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