Introduction

● Type 2 diabetes mellitus (T2DM) is rapidly increasing worldwide, with 589 million individuals affected in 2024.

● Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have become widely prescribed for glycemic control and weight management.

● While these therapies provide significant benefits, their effect of delaying gastric emptying raises important concerns in the perioperative setting.

● Delayed gastric emptying is associated with an increased risk of pulmonary aspiration during anesthesia. Suggestions from the American Society of Anesthesiologists reflect this uncertainty, with guidance allowing continuation in low-risk patients but suggesting liquid diets for higher-risk groups.

● Gastric point-of-care ultrasound (POCUS) has emerged as a practical tool to assess aspiration risk by directly visualizing gastric contents.

● Purpose: This review highlights the physiologic effects of GLP-1 RAs, their perioperative implications, and the role of gastric POCUS in improving anesthesia decision-making and patient safety.

 

Results

● Dose & Duration Effects: Long-acting GLP-1 RAs (e.g., semaglutide, tirzepatide) are more strongly associated with retained gastric solids than shorter-acting formulations.

● Study Data: Observational data show GLP-1 RA users have ~10× higher rates of gastric residue compared to non-users.

● Cohort Evidence: Retrospective analysis of >200,000 patients undergoing orthopedic surgery found that stopping GLP-1 RAs 7 days before surgery lowered risk, but 14 days showed the lowest complication rates.

● POCUS Utility: Ultrasound can differentiate low-risk (empty or small-volume fluid) from high-risk (solids or large-volume fluid) gastric states and is validated across obese, obstetric, diabetic, and pediatric populations.

● POCUS provides a grading framework (Grade 0: empty, Grade 1: low-volume fluid, Grade 2: high-risk solids/fluid).

 

Conclusions

● GLP-1 RAs are increasingly prescribed and provide clear therapeutic benefits, but they raise perioperative aspiration concerns due to delayed gastric emptying.

● Current fasting and medication withholding strategies do not consistently prevent aspiration risk.

● During this period of uncertainty, gastric POCUS is a practical tool to improve perioperative decision-making and patient safety during procedures.

● Future studies are needed to refine aspiration risk stratification and optimize management strategies for patients on GLP-1 RAs.

● Aspiration events, while uncommon, can have severe consequences; case reports describe regurgitation and airway compromise even after >10 hours of fasting.

● Standard fasting and medication-holding guidelines are not protective for all patients, supporting the role of individualized ultrasound assessment.