Good afternoon, everyone. My name is Rhea Temmerman. I'm a member of the ANA's Professional Development Committee, and it is my pleasure to welcome you to our 2024 Hybrid Annual Congress. So you guys having a good time so far? Woo! So we're excited to have you join us both in person and virtually, but before we begin the session, I have a few announcements. So for everyone here in the room, you have to download the app and select the ANA Meetings app from the Apple Store or Google Play, and select ANA 2024 Annual Congress. You log into the app using your ANA.com credentials and use the mobile app to access the conference schedule, the speaker bios, and download any session handouts when applicable. But most importantly, you need the app to claim your CE credits. So from the screen page, when you click on the Evaluations icon at the bottom of the screen, you fill out and submit it for each individual session, and the eval will open 15 minutes before the session ends. We do recommend that you fill the eval out immediately after you attend each session so that they don't pile up. For those that are joining virtually, you'll find the same information on the schedule page of the website within each separate live stream session. The attendees have until Monday, September 9th at noon Pacific time to submit all the individual evals and overall conference eval. And following this date, if you don't do it, you're no longer going to be able to claim your CE credits for the annual Congress. You can send questions to the speaker via the Questions icon in this app, and I'm going to monitor the questions and ask them at the end. If you're attending in person, you could come up to the mic between each aisle and ask questions as well. Lastly, to promote awareness on this topic, attendees can stop by the ANA activation area in the Expo Hall to perform a live gastric ultrasound scan using a handheld transducer and guided by the BlockBuddy app. You scan your badge with the staff member at the station to submit for Class B credits. And now, it is my pleasure to introduce to you my friend, Dr. Amy Reed. Dr. Reed is the Assistant Program Director of the York College of Pennsylvania WellSpan Health Nurse Anesthesia Program. So please join me in welcoming Dr. Reed as she presents glucagon-like peptide 1 receptor agonist and the risk of pulmonary aspiration, an update on current recommendations and the utility of gastric ultrasound. All right. Good evening, everyone. As Rhea said, my name is Amy Reed. I'm the very proud Assistant Program Director of the York College of Pennsylvania WellSpan Health Nurse Anesthesia Program in York, Pennsylvania. I would really like to thank our Program Director, Dr. Jason Lowe, and the WellSpan Health System for allowing me this opportunity to come and speak to you this evening. I would also like to thank my mentors, Dr. Richard Hawes and Howard Bertinette. They have since retired, but I wouldn't be a nurse anesthetist without them, and they're very near and dear to my heart, so I want to give them a shout out. And I would like to thank all of you for being here as well, both in person and virtual. I really hope this presentation proves to be beneficial to your practice and, of course, your patients. So just to give you a little bit of history, I started studying gastric ultrasound and the utility of it in pulmonary aspiration and anesthesia around 2015, 2016. I like to say I was studying it when it wasn't cool, and now here we are, and everybody really wants to learn it, and our national organizations are asking us to learn it. When I was studying it very early on, it was met with a lot of skepticism. I would have providers say to me, Amy, we've been intubating for decades upon decades. Why do we need to learn pulmonary or why do we need to learn gastric ultrasound to prevent pulmonary aspiration? We already do a pretty good job. And truthfully, their statements are valid, and they continue to be valid. If you look in the literature, the incidence of pulmonary aspiration is pretty low. In fact, in June of 2024, so just two months ago, Rumenbaum, Mahi, and Nickel published an article that cited in retrospective studies the incidence of pulmonary aspiration is less than 0.04%. In prospective studies, it's less than 0.07%, and that was looking at adult and pediatric patients presenting for elective surgery. If we jump over and cross the pond into the United Kingdom, Ed Moss and colleagues found in a national audit report that for fatal pulmonary aspiration, the incidence was one in 300,000 patients. So yes, the incidence is low in the literature, but we also know that pulmonary aspiration is under-reported and that micro-aspirations occur far more commonly in the perioperative setting. And lastly, why we're here right now, the increasing amount of patients coming to your operating room taking glucagon-like peptide 1 receptor agonists, GLP1s. This is why the anesthesia providers of 2024 are far more interested in the utility of gastric ultrasound compared to those practicing in 2015. In addition, I've been presenting on this topic now for quite some time, and it's amazing to me that even just two or three years ago, a tool or technique that was kind of considered really not that valuable. Now in 2024, again, our national organizations are asking us to learn this because point of care ultrasound and specifically gastric ultrasound, it's really important for our patients and our practice. So let's get some housekeeping out of the way. I have no conflict of interest, and our learning outcomes for this evening is going to be to review the current recommendations around GLP1 receptor agonists, and we're also going to talk about the pillars of gastric ultrasonography and how you can use it when you're questioning the NPO status of your patient, which actually goes far beyond just our GLP1 receptor agonists. For an agenda today or a roadmap, we're going to look at the impact of GLP1 receptor agonists in health care and society at large. We're going to talk about the physiology of our patients and the pharmacology of these drugs. We're going to look at anesthetic considerations, and then we're going to look at current literature and the recommendations that are recently being published. This is actually weaved throughout the presentation, but honestly, the research is coming out daily about this information, and so I want to highlight about two or three articles that have been recently published, and we'll do sort of a summary of what we know today. This will lead us into point-of-care gastric ultrasound. I don't know if any of you attended my presentation in Seattle, but we did live scans. I am hoping to do live scans tonight, but instead of me doing it, you can think about this now. I'd like to have some volunteers to come up and do it to show you really how easy it is. I've been presenting on this, and I've kind of collected some frequently asked questions. I will add those to the presentation, too, and hopefully they answer some of your questions, and I will take questions and comments at the end. Truth be told, I can talk about this for a while, so I am going to try to make room for questions. And with that, at the end of the presentation, I do have my email address, so please feel to email me with any questions or comments or if you need any resources as well. So let's get started. The impacts of GLP-1 receptor agonists. If you watch television, if you're on social media, if you listen to any type of news outlet or you listen to satellite radio, it's really hard to avoid the jazzy jingles and the colorful commercials of our GLP-1 receptor agonists. Dr. Kemper, who was the former president of the Association of American Surgeons and Physicians, he said that advertisements for these medications are occurring three to five times per hour on most television channels. Now, truth be told, I don't know how he got that information exactly, but anecdotally, if I think back to listening to 30 minutes of the news, I bet you I've heard at least one or two of these advertisements. So I think what he's saying is pretty accurate. These blockbuster medications are impacting far more than the way we plan an anesthetic for our patients. They're redefining healthcare. And they're changing the way society looks at obesity and weight loss therapies. As these medications have taken on an additional role, if you will, from their original intent, which is to help treat type 2 diabetes, and it's still doing that, right, but it has also contributed $100 billion to the weight loss therapy industry. That's pretty incredible. When you speak of these medications, it's as if, sorry, they are the latest and greatest medications. But these aren't exactly what I would call new medications. In fact, Baydurian and Viata were approved by the FDA in 2005. In 2010, Vicosa was approved for the adult patient population. And then in 2019, Vicosa was approved for the pediatric patient population over the age of 10 years old. 2019 was a big year. This was when Rebelsis came out on the market, which was the first oral GLP-1 receptor agonist. In 2024, just this year, Wachovia was approved to reduce cardiovascular deaths, strokes, and heart attacks in overweight and obese patients with cardiovascular disease. But if I had to pick a year where these really became popular, it was the year of 2022. This was the year that celebrities lost large amounts of weight in an incredibly short amount of time. I never thought I'd be citing the Today Show in an anesthesia presentation, but here we are. The Today Show did an editorial that followed 16 celebrities. They included people like Oprah Winfrey, Charles Barkley, Tracy Morgan, Amy Schumer, and they followed them through their weight loss journey using the GLP-1 receptor agonist. TikTok pushed out a hashtag, Ozempic Weight Loss, which caused awareness and prescriptions for these medications to skyrocket. Between the year of 2020 and 2022, the prescriptions for these medications increased by 300%. That's incredible. And just this year, between January of 2024 and March of 2024, 25,000 Wengovia prescriptions were written each week on average. These medications are not going away. And the impact that these medications have are not only in healthcare, but society at large. I want to give you a few examples. Bariatric surgeries are projected to have a law or a decrease in the future because patients are losing the weight they need. There may be an increase in eligibility for patients to receive procedures such as kidney transplants because they're losing the weight in order to meet that strict cutoff for BMI so that post-operative complications are minimal. These medications are looked at and being researched currently to help with sleep apnea, addiction and depression, as well as anxiety. And probably the most recent potential treatment using these drugs is to prevent or slow cognitive dysfunction. I really wanted to come here today and give you the latest and greatest, and I really thought I had it. And I was going to tell you about a systematic review that was published in April of 2024 that said, hey, we looked at the literature, and GLP-1s are not helping to decrease the amyloid beta and tau biomarkers for Alzheimer's disease. Oh, and they're not really preventing cognitive decline. But I was cooking dinner for my children on Tuesday, and in the background I hear Lester Holt on the nightly news saying, weight loss medications today, there's research out showing a cognitive decline and benefit for these patients. I was like, hang on, Lester, wait a second. I just looked at the literature. So I do it again. And guess what? Lester was right. On Tuesday in Philadelphia at the Alzheimer's Association Conference, literature, well, it's not actually even literature yet. It's not peer-reviewed, and it's not published. But the experimental data is out there, and they presented on it saying that there is an improvement in cognitive decline. How is this working? They think it's because of the anti-inflammatory properties, and it's decreasing insulin resistance in the brain. More to come. Also, the spillover phenomenon for these medications is huge. Walmart has reported a decrease in junk food and an increase in food that's termed healthy or low-calorie. And probably one of my favorite tidbits about all of this is that the airline industry is projecting a decrease in jet fuel due to the hope for lighter passengers. Now I don't know if we're going to see that price trickle into our tickets, but maybe next year when we go to Nashville, we can take another suitcase or a carry-on or something, right? If we're all lighter, then we should be able to take an extra bag. Look, as nurse anesthetists, we are trained, very well trained, to handle things on the fly, and we're really good at it. But we would much prefer to know what we're getting ourselves into, which is why tons of research is coming out every day. And I would project in the next year, three years, five years, it's not going to stop. Because we don't know a lot about these medications. Guys, this is live footage of me at our ambulatory surgical center. When I find out that my next patient is on a GOP1 receptor agonist, is scheduled for a MAC case, oh, and the facility doesn't have a curvilinear probe. Oh, but better yet, the patient had a gastric sleeve done. So I can't use the ultrasound anyway. And then this is me when the case gets canceled. Let's look at these medications through the lens of a physiologist and a pharmacologist, also known as a nurse anesthetist, right? So we know that these medications originally were prescribed for type 2 diabetes. So let's take it back to A and P, right? What does that mean? Well, it's usually a twofold problem. It's usually a problem with insulin resistance, and then a problem with insulin secretion. Insulin resistance, what does that mean? It means that the insulin that's normally secreted from the beta cell of the pancreas and travels in the plasma, in the bloodstream, and gets to our skeletal muscle, our adipose tissue, and our liver cells, hit the receptor. And there's tyrosine cross-phosphorylation. There's the GLUT4 receptor that gets translocated to the cellular membrane, and that allows glucose inside the cell. What happens with diabetes is that that insulin and the insulin receptor are not communicating properly anymore. What does that mean? That means we don't get the GLUT4 translocation, and glucose doesn't come into the cell, which means we still have high plasma glucose. The second thing is the decrease in insulin secretion. Well, why does that happen? Well, this is the problem with the beta cell of the pancreas that normally secretes insulin. There's a GLUT2 receptor on that. And due to lipid toxicity, that GLUT2 receptor in type 2 diabetes is inhibited. So it doesn't allow glucose to come into the pancreatic beta cell to get insulin secretion out. Let's look at some pictures. So here's the beta cell of the pancreas that would normally secrete insulin. If that is inhibited, if the GLUT2 receptor is inhibited, what normally should happen is we should have glucose come in, we should have an increase in millivolts due to the closure of a potassium channel, which is a cation channel, right? So it's not letting potassium follow its concentration gradient from inside to outside the cell. So it closes. By closing and allowing that cation to stay there, we get an increase in millivolts in our cell. We get an action potential. We get depolarization of the membrane. And that opens calcium channels, voltage-gated calcium channels that normally allow calcium to flow inside the cell, or from outside the cell, rather, to inside the cell following its concentration gradient. The old androgen anesthesia school was what? Calcium in, neurotransmitter out. Well, in this case, the neurotransmitter is insulin. And in type 2 diabetes, we never get that secretion. Let's look at the skeletal muscle cell, the adipose tissue cell, as well as the liver. Normally what would happen, the insulin would hit the receptor, cross-phosphorylation, GLUT4 receptor, we happily get glucose inside the cell, which can be used immediately or can be stored for a later date. Again, the communication between insulin and the insulin receptor are not occurring in type 2 diabetes. Let's look at the GLP-1 receptor farm. These medications are a class of medications that are also called incretin mimetics. And incretins are very important to maintaining glucose homeostasis. We actually have them endogenously. So we produce them from the intestinal L cells in our colon. We produce two main type of incretins. One is the glucagon-like peptide one, our GLP1s. And the second is a glucagon-dependent insulotropic polypeptide, short for GIP. Remember that. Because when we talk more about what the FDA is doing in a few slides, you'll want to remember that incretin. These incretins do wonderful things. They suppress appetite. They increase insulin utilization and secretion. They also create an anti-apoptotic effect. Apoptosis is cell death. Well, if we're not killing off our beta cells, then we're getting more insulin secretion. So very important. So incretins are really special. Well, if we make them in our bodies anyway, if they're endogenous, then what's the problem? The problem is they get degradated fast. They have an incredibly short half-life, one minute to one and a half minutes. And this is due to dipolypeptide peptidase 4 enzyme, DPP4. This degrades our endogenous enzymes very quickly. Our exogenous GLP-1 receptor agonists do not get degraded by DPP4. And therefore, these synthetic medications have been proven to do everything the incretins can do, but just for a longer period of time. I want to highlight, as a nurse anesthetist, we're really worried about the regurgitation, the pulmonary aspiration, and really, even more so, the lack of evidence around gut paralysis and gastroparesis, rather. But these medications have really good benefits for our patients. Yes, we know it decreases plasma glucose. And yes, we know that it promotes weight loss and suppresses appetite. But it's also been shown to help with lipid disorders. It's also been shown to help with fatty liver problems. It's also been shown to delay diabetic-related neuropathy. And it's been praised for its cardiac and renal benefits as well. So there are some good things here. But great, what does that mean for us when they come to our operating room? Let's look at some anesthetic considerations. But before I do that, I actually want to talk about some specific GLP-1 receptor agonist considerations, if you will. These medications are in such high demand. And they also are very, very expensive. High demand means we're going to have a shortage, right? So in May of 2023, semiglutide injections were placed on the FDA drug shortage list. These medications are also very, very expensive. Becker's reported that $32.8 billion was spent on semiglutide. So that's our ozempic and our Rwangovi in 2023. And on Menjaro and ZepBound, it was $13.2 billion in 2023. The average cost monthly for patients on these medications is anywhere from $500 to $1,300. Lots of insurance companies are not paying for this. They might pay for it for the cardiovascular aspect of it, but certainly not for weight loss. So these jugs are not cheap. Dr. Eric Tickey was a former chair of the End Drug Shortage Alliance. And when he talked about GLP-1 receptor agonist, he said that the biggest side effect was sticker shock. What's happening if we have drug shortages? People try to find other avenues to utilize this medication. So in May of 2023, when semiglutide was placed on the FDA drug shortage list, they also put out a warning saying, hey, do not take the salt compounds of these medications. The salt compounds are semiglutide acetate and semiglutide sodium. And the problem with these medications is that the active ingredient is not exactly the same. And it hasn't been researched enough for its safety and its efficacy. So what happens there? That can be a lot of errors and a lot of administrative error problems, right? So Powell and colleagues, they highlighted this specific issue. And they also said that the injections, the injection cartridges, are not regulated either, which also leads for an opportunity for error for these medications. Wilson echoed this, saying, we have big concerns with these sodium and acetate salt compounds. So people are trying to find other avenues to utilize these drugs. In addition, weight loss centers are, I say, giving them out, are prescribing them, aesthetic centers as well. People are also going to online pharmacies as well as other countries. When I talk about the cost, I forgot to mention that in April, the cost of these medications being so high, in April of 2024, the Senate committee opened an investigation to understand why. These medications are 15 times higher in the United States than they are in other countries. There's some food for thought there. To combat this shortage, the FDA has recently approved what they're calling a second generation GLP-1 receptor agonist. And it's really not just a GLP-1 receptor agonist. It's a GLP-1 and a GIP. Remember from our Incretin talk? That's the other major Incretin. So they've combined these two medications, and they're having great success. And hopefully, it's combating the shortage of the original first generation GLP-1 receptor agonist. In addition, there's a third generation medication that is in experimental studies that's also showing promise. This is a, brace yourself, a GLP-1, GIP, GCG-R receptor agonist. They're calling it a tragonist, because it's a triple threat, right? So this medication, in experimental studies, has been shown to decrease 24.2% of a person's weight loss in a 48-week period of taking the medication. So pretty impressive stuff. If you want to know how the tragonist works, it's on a G-coupled protein receptor, GS specifically. And we know that means stimulatory. So we know that the G, stimulatory protein, has an alpha, beta, and a gamma subunit. That alpha subunit, when it's activated, is going to break off. It's going to activate and stimulate adenylate cyclase in the cellular membrane. We're going to get our activation of ATP to cyclic adenosine monophosphate, our cyclic AMP, which is going to activate protein kinase A. That's when we get a lot of awesome cellular effects, right? And some of those cellular effects that's happening with this tragonist, if you will, is anti-inflammatory properties, anti-apoptosis. So again, we're not killing off our beta cells. And also some neuroprotective benefits as well. A lesser known mechanism of action, or I guess it's just not as talked about as much, is that this type of medication also acts on an insulin receptor substrate. And that has a lot of complex kinases on the downstream effect that's doing similar things to our cyclic AMP effects as well. Anesthetic considerations. So of course, the biggest one that we talk about and the one we are most focused on is delayed gastric emptying or gut paralysis. I want to caution you with this, because there's some literature out there that actually states that in the first 12 to 20 weeks is when the patient is most at risk for regurgitation, gastroparesis, having gastroparesis symptoms. And that after 20 weeks, your gut motility goes back to normal. There's also other studies out there that say that's very variable. That you can have patients where that does happen to, and they do normalize their gut motility. And then you have patients that don't. So they are saying to utilize gastric ultrasound if you're unsure. So don't be confused. Just because your patient has taken it for 25 weeks does not mean you're out of the woods. There's also other considerations with these GLP-1 receptor agonists. So if it's taken alone, so if you're just taking that for diabetes, there's really not a risk for hypoglycemia. However, if you're taking it with other oral hypoglycemics, such as metformin, or you're taking it with insulin, then yes, this is absolutely a consideration for hypoglycemia. In addition, acute pancreatitis has been noted, dehydration, cholelithiasis, cholecystiasis. And truthfully, the long-term effects of these medications are still not known. They are saying that if the liver is, if you have severe liver disease, or if you have severe kidney disease, these medications should not be taken by those types of patients. Current literature and recommendations. So let's start from what we know and what everybody's talking about is the ASA recommendations. They came out in June of, June 2023, so just last year. It was June 29. And what the ASA recommendations are saying is, hey, there's not a lot of evidence out there. However, that if the patient is taking the oral medication daily, they should hold it for a day. If it's weekly, they should hold it for a week. And if the patient didn't hold it, but they're not having gastroparesis symptoms, they still should be considered a full stomach, and you should utilize gastric ultrasound if it's feasible and if you have somebody trained in it. Well, in February of 2024, a correspondence was published in Anesthesiology. And they called for the ASA to update their recommendations for GLP-1 receptor agonists. They also called for an algorithm to be made, almost like our difficult airway algorithm. And this algorithm, they demanded to have gastric ultrasound included in that as part of that algorithm. Jones, Hobiei, and Murphy, they challenged the provider that if your patient is taking the medications for weight loss, it should be held for three half-lives. For medications like Ozempic, that's one week, is one half-life. So they are saying it should be held for three weeks. That provides 88% clearance. They're saying if the medication is utilized for weight loss, if the medication is utilized for type 2 diabetes, then you should consult an endocrinologist. However, they stop there. There's nothing else saying what that endocrinologist might say about it. And lastly, they say to utilize gastric ultrasound if it's feasible. In Anesthesiology in April of 2024, Milder was cited. He looked at implications for perioperative practice. They say, quote, there is insufficient evidence to provide definitive guidelines for GLP-1 receptor agonist, end quote. And they echo the previous researchers in saying that if the medication's for weight loss, it should be held for three half-lives. If the medication is for diabetes, we should consult an endocrinologist or utilize gastric ultrasound. Nelson also suggests this. And they also talk about the fact that prolonging fasting guidelines for these patients is probably not going to work. And we all know that there is detriment to having patients fast longer than necessary. Dehydration, and also for type 2 diabetic patients, it alters their plasma glucose. So what's the summary? From everything I've read over the past few months with this, number one, insufficient evidence for definitive guidelines, which is probably why we haven't heard from the ASA quite yet. Two, weight loss, hold it for three half-lives. Diabetics, consult an endocrinologist. But I think they're going to tell you that they still need to take it and you should do a rapid sequence induction. And, that's just my two cents, and utilize point-of-care gastric ultrasound. Which leads us to point-of-care gastric ultrasound. We're being asked to learn this. And so the big question is, how is this getting implemented? And how are we training people to do this? Well, I was literally just asked on Wednesday, right before I came out here, from one of our clinical sites, to train 80 people on gastric ultrasound. Will I try to do it? Sure. Will I do it quickly? Probably not. Is that feasible? No. Grassroots. It's our anesthesia programs. We need to add it to the curriculum. That's number one. We need to be graduating 10, depending on the size of your program, to 40 students every year, that are competent in gastric ultrasound, and really point-of-care ultrasound, because that's really leading the way. In addition, you're here tonight. You're here to listen about a lecture. You're here to listen about gastric ultrasound. But also, you can see it was sold out. The ANA is providing opportunities as well. And my guess is some of you probably attended this workshop. And then of course, we need to practice, practice, practice. A little tidbit, when I was learning gastric ultrasound, and I was trying to practice, and you'll see this hopefully when we do the live scans, if you drink carbonated, I would try to identify what I was looking for for the antrum, and I would have my family member drink carbonated liquid, and then you could just see the front of my mouth. And the fluid go into the antrum, and that's how I knew I was identifying the correct spot. So if you want to try it, you know, when you get back home. I get asked a lot, well, how long till I'm proficient? Well, this is an old article, but it's a good one. And I haven't seen anything too recent that changes what they originally said, which is that after 33 scans, under the supervision of somebody who knows what they're looking at, right? You can become over 95% accurate in your assessment, both doing the technical skill of it, and then also identifying correctly what is in your patient's stomach. I also get asked, well, should we scan everybody? And no, that's currently not recommended in the literature. However, there's these two umbrella categories that are talked about frequently. First is if they have an unknown perineal status. Second is if they have a comorbidity associated with gastroparesis or delayed gastrogenthine. For the unknown perineal status, this is your patient with cognitive or acute neurologic dysfunction. If they're a poor historian, or perhaps it's a language barrier situation. And many articles actually cite pediatrics as a unknown perineal status population. And I know from having toddlers, that's absolutely true. All of a sudden I see them chewing something and I don't know where it is or where they got it from. I don't know how old it is. It was stuck in their car seat. I mean, it could be a toy, who knows, right? So they are absolutely an unknown perineal status. And then for delayed gastric emptying, here we're looking at patients in acute pain or chronic opioid use. Do they have chronic kidney disease, obesity, GERD, or type 2 diabetics? And a lot of the research with type 2 diabetics is poorly controlled type 2 diabetes. What's their hemoglobin A1C? And do they have any end organ damage? If that's the case, then we probably should be scanning them because we would worry about an increase in gastric contents preoperatively. Okay, so let's say your patient falls within one of those two categories. You go into pre-op with your ultrasound. How are you gonna do it? Well, first thing's positioning. We wanna position our patient in the right lateral decubitus position. Why the right lateral decubitus position? Well, this allows gravity to help us, right? Gravity will take the stomach contents and let it travel to the antrum of the stomach. This is what we're measuring. Now, with ultrasound, you can see the fundus, the body, and the antrum of the stomach. However, the antrum has been shown to look at gastric contents in totality. So that's our best place to look at gastric contents. Your probe. You're going to want to use a curvilinear probe if they're over 40 kilograms. If they're under 40 kilograms, such as our pediatric patient population, this is when you can utilize a linear probe. You're gonna place it in the sagittal plane right below the sternum, and we'll see that in our live scans as well. But there's some really important anatomy I wanna cover. First and foremost is you have to find the border of the left lobe of the liver. If you don't see that, you could be out in no man's land in the intestines thinking you're seeing the antrum moving and it's really an intestine with peristalsis. So finding the border of the left lobe of the liver is imperative. You will see other structures in most of your perineal states, such as the aorta. If they're really thin, you might see the spine, the vertebrae. You'll also see the pancreas and the superior mesenteric artery and the superior mesenteric vein. We also look at gastric ultrasound in sort of two measurements. First is gonna be the qualitative. So this is as if you're looking at the patient's antrum and you're trying to decide, is it empty? Is there fluid in there? Or are there solid substances? If it's empty, you're good to go. You're headed to the OR. If there's solid substances, well, then maybe we're using pharmacological agents. Maybe we're changing our anesthetic plan to a rapid sequence induction. Maybe we're delaying the case or canceling it. But if there's fluid, then we can measure to see how much fluid is in the patient's stomach. What we want to know here is the patient at risk for pulmonary aspiration with the amount of fluid, or is it just really baseline secretions? So just because you might see some fluid in the antrum of the stomach does not necessarily mean they're considered high risk for pulmonary aspiration. This is an empty stomach. This is what you want to see. This means, this is the green light to go back to the operating room. You can see the left lobe, the border of the left lobe of the liver. And you can see the antrum has the big letter A on there. It's an anechoic ring with hyperechoic tissues, or it looks like tissues in there. Well, it's actually the five layers of the stomach. So this is an empty stomach. This is called the bullseye. This is a fluid-filled stomach. Notice that you don't see those tissue layers anymore, because now we have a descended antrum. This descended antrum is clear fluid, and sometimes you'll see some hyperechoic dots. And this is as if the patient, they could have taken in a lot of air when they were drinking. Or maybe they drank a carbonated beverage. That's what you would see. This is the picture, the perineal state, in which you can measure the antrum to see if they're at risk for pulmonary aspiration due to the fluid, or if it's just baseline secretions. I wanna show you this chart here, because how much fluid is too much fluid? The literature states that 1.5 mLs per kilogram or higher is considered to be a high risk for pulmonary aspiration. If it's less than 1.5 mLs per kilogram, it's considered low risk. So what does that mean? That means if your patient, let's say you had a 60-year-old patient, and you measured the cross-sectional area of the antrum with the ultrasound, and it was 13 centimeters squared, and your patient's 70 kilograms. So first you need to figure out, what is baseline secretions for my patient? So that's 1.5 mLs times 70, that's 105 mLs. Now, we measured the cross-sectional area of the antrum to be 13. So when we use this chart up here, the question is, is it above the 1.5 mL? So is it above 105 mLs in the antrum of the stomach, or is it below that? So if we look here, we said they were 60 years old, and 13 centimeters was the measurement of the antrum centimeter squared. We go over and we see that it's 140 mLs. That's above the 105 mLs that was considered baseline secretions. So your patient would be considered to be a higher risk for pulmonary aspiration. Where did we get this chart? Well, we'll talk about her a little bit later, but the queen of gastric ultrasound, in my opinion, is Dr. Anna Perlis. And she has been looking at gastric ultrasound since the early 2000s. And this is the equation that's utilized in order to make this chart, because she knows that the busy clinician is not gonna take out their phone or their calculator and plug this in bedside, right? You need a quick cheat sheet, if you will, to figure out quickly if you're okay to go back to the operating room or not. And so that's where this chart came from. This perennial state here is what's called thick fluid or late digestion. This is, for example, your, I don't know, do you guys have Smoothie Kings on the West Coast? Wherever you get your smoothie in the morning, that's as if your patient stopped there and drank it. Or it could be that they had a full meal, but it maybe was four to six hours ago, not one or two hours, cuz that'll look a little different, and that's in our next slide. But what's important here is that you can see the margins of the antrum, but you can not measure the antrum in this state. We can see it looks very different, right? So we see it's more hyperechoic, where our clear fluid here was completely anechoic. Clear fluid, had creamer with their coffee in the morning, okay? So completely different, this is considered a full stomach. You can not measure the antrum in this state, it would be inaccurate. It's not fluid, it's solid substances. This is as if your patient went to an In-N-Out burger, and then was driving on the 409 here, and got hit by a tractor trailer and is now in your trauma bay. This is somebody who immediately ate. This is called the frosted glass appearance. What's special about this picture is notice you can't identify any structures that are posterior to the antrum. So we don't see the aorta, we don't see the pancreas, and we don't see the superior mesenteric artery and vein. This is why I said it's so important to find the liver, the left low liver border, okay? You have to find that. If you don't find that, again, you can be in no man's land. So this is just looking at all of them and comparing. So the empty stomach, again, is the bullseye appearance. We see the five layers of the stomach. In the fluid filled or clear fluid, we see a very anechoic ring or structure rather with anechoic in the middle. This is clear fluid. For late stage digestion or thick fluid, again, consider the full stomach here, and we can see the borders of the antrum. But this would be inaccurate to measure with the ultrasound for the fluid like we did for clear. And then lastly, the full stomach, the person that just ate, and that's the frosted glass appearance. If you remember when I talked about positioning, I said, turn them on the right lateral decubitus position. If you read a lot of the literature, they tell you, measure them supine and then turn them in the right lateral decubitus position and measure them again. Well, why did I tell you just to turn them? Well, this is because you cannot confirm an empty stomach in the supine position, I'll repeat it. You cannot confirm an empty stomach in the supine position. And not only that, you can't measure, if there's clear fluid in there, you can't accurately measure the amount of fluid if they're not turned on their side, because we need gravity working for us. So why does a lot of the literature say supine and then right lateral decubitus position? It's because of this chart. This is an actual grading chart. So if I measured a person, or if I had them supine and measured them and I didn't see anything, and then I turned them in the right lateral decubitus position, and I still didn't see anything, they're considered to be low risk. This is considered to be less than baseline secretions even. If I measure them in the supine position, and then I turn them on the right lateral decubitus position, and I do see something, but I didn't see anything in the supine position, they're still considered low risk. This is a grade one antrum. And then if I scan them in the supine position, and I saw fluid, and I turned them in the right lateral decubitus position, and guess what? I still saw fluid. This is a grade two. This is considered to be high risk. So this is the way the researchers look at it. For the busy clinician, if you just turn them on the right lateral decubitus position, it's gonna tell you everything you need to know. Is it empty? Great. Do I need to measure it? I'm already in the optimal position. Let's measure it and figure out if the amount of fluid is gonna place the patient at pulmonary aspiration risk, or if it's gonna be considered low risk. I deemed her the queen of gastric ultrasound. I'd hope she'd take that as a compliment, cuz I certainly mean it that way. But this is Dr. Anna Perlis, and as I mentioned before, she has been researching this since the early 2000s. And she truly has made the gastric ultrasound and published about the validity, the reliability, the feasibility of it. When I was doing my doctorate at the time, I was really sweating it, because I thought, my gosh, I really wish this would be valid in obese patients. Because we all know we have a lot of obese patients that we could be measuring. And it was about two weeks before I was about to start my research, and she published an article validating gastric ultrasound in the obese patient population. So she's looked at it from healthy people to obese, to diabetics, to pediatrics, all sorts of different patient populations. And she's also the one that published the equation that I showed you on the chart. Should we do some live scans? Okay, we have a few minutes. I can't see everybody, so I don't know if you're as excited as I am. No? Yes, I see some hands, all right. Do I have any volunteers? Okay, I see a lady right here. Exciting, and one of my beautiful models, whichever. If we could switch over to the ultrasound image, our wonderful IT people. If you want to come around here, you'll probably have a better. Okay, tell us your name and where you're from. I'm Katherine Scott, and I'm from Oklahoma. Oklahoma, well, welcome. Thanks for volunteering. Yeah, all right, have you done it before? Okay, my gosh, I love the, just jump right in. I'm gonna come around here so I can get out of the way. All right, so Emily here. Emily's a junior in our anesthesia program at York College WellSpan Health. So she's very new to clinical. She just started, it's very exciting. Okay, so Katherine, go ahead. And you want the indicator up, cephalad towards the head, perfect. And then you're gonna go, yep, that's the indicator, yeah. And then you're gonna go in the middle, right here, below the sternum. In the sagittal plane, perfect. And I probably have you, right. We're gonna decrease the depth for Ms. Emily. Okay. So you kind of just eyeball your patient, right? So if they're real thin like Emily is, you can go anywhere from like 10 to 13, maybe even 14, but if they're a little bit heavier, sometimes I'll just go to 18 for depth, okay? All right, so what do you see? I see the liver, right, right here? Yep, and the aorta, and we also see some of the vessels. So in this case, we're gonna want to come down here and over, okay, perfect, and down, all right, good, okay. Emily, take a deep breath, go ahead, do it one more time, okay. And then we're gonna move, Emily, take a deep breath, go ahead. All right, do you see? It's very tiny up here, let me get a cursor. All right, up here, right next to the lobe of the liver, you look pretty empty. Is it, yeah, are you hungry, you poor thing, okay, perfect. Emily, I'm gonna have you drink this, who shook this before they brought it over? All right, we're gonna have you drink, and then you can actually put the ultrasound on, let's see, all right, and then we're finding the. Emily, I hate to tell you, you're probably gonna have to drink more than that. Chug, chug. All right, see it right there, you see how everything's coming in? Yes, so I just froze it here so we can take a look. But right here, you can see the bubbles coming in too, how do you feel about it? Do you think you'll try it? I'll try it. You'll try it? Yeah. Let's give a round of applause for Catherine. For your participation, you get the Your College WellSpan mug for our most recent mug, yes. Oh, thank you. Thank you, Emily. Here, I'll let you do this one. Anybody else wanna try? I see, in red, right there. Your shirt, I can't really see a lot of you, and we'll have McKenna come up, perfect. That's good, we'll look at all different things. Tell us your name and where you're from. I'm Takora from Asheville, North Carolina. I'm glad to be here. Woo, welcome, thanks for volunteering. Have you done it before? I've done it before. Good, all right. Okay, good, open the indicator up so it'll go back. I'll move this so we don't have any accidents. McKenna, I'll have you go a little bit more. Yep. And then you're gonna wanna turn it in the sagittal plane, perfect. Yep. We'll unfreeze here. All right, good. Oh, so did you see that frosted glass? So you would be considered, here, let's move it down just a hair to get an end of view. I would say that that's kind of a late-stage digestion, true? I ate at 11.30. You ate at 11.30, okay, yes. So late-stage digestion, you can still see the margins of the antrum. However, it's not completely anechoic, so it's not just clear fluid. There's definitely some solid substances still in there. We'll still take you to dinner, though, McKenna. All right, good. All right, let's give a round of applause. You also, I mean, I know it's not your program, but you can still, it's still a really pretty mug. I'll take it. Okay, thanks. I think we have time for one, maybe one more quick. Okay, oh, a really excited person there. Yeah, come on up. And I have a, oh, you have pants on, okay, good. We almost had a, we could have a wardrobe malfunction, right? All right. Hi, what's your name here? I'm Carrie. Carrie, and where are you from? Portland, Oregon. Portland, Oregon. Oh, welcome, all right. Have you done it before? No. Okay, all right, here we go. And this is the end of it? Oh, no, the other one. I know there's two, but it's the long one. It doesn't make sense. Sorry. There we go. Oh, I see it. You see it. Do you see it there and all the good stuff moving? And you have a picture here where you can see the left lobe of the liver, so right there. So you have some remnants as well of food. I ate that too. You ate it too. All right, there we go. So, yes, so she still has solid substance in there. And notice, Mamaua, again, like the aorta's there, and you can start to see some of the vertebrae too. Oh, yeah. Perfect. Well, let's give a round of applause. And you also, Carrie, get a program mug. Thank you. And a round of applause for our models. Thanks, Mamaua. All right, perfect. If we could switch over to the PowerPoint, I'll just finish up quick. I have five minutes. All right, perfect. So frequently asked questions, so hopefully this will help with some of the questions. When can you not use gastric ultrasound? If they have a history of gastric surgery, so a Roux-en-Y or a gastric sleeve, no go. It would be inaccurate to use it, especially if you're measuring for fluid and such. Large hiatal hernias, obviously if they have abdominal wounds or bandages, you're not going to be able to get to the area you need to. Oh, and notice, cannot tolerate the right lateral decubitus position. This is because you cannot confirm an empty stomach in the supine position, so you have to turn them in the right lateral decubitus position. How long does it take? I used to answer this anecdotally because when I was doing it a lot for my research, I could be in and out of a patient's room in under about three, three and a half minutes. Here they looked at new residents learning how to do it, and they were doing it in the operating room, and they could do it in four minutes. So it can be pretty quick. And a lot of times while you're doing your preoperative assessment, you can be talking to them, asking questions, and doing it. And I find that a lot of patients really get a hoot out of it because they really want to see, oh, they're like, what are you looking at? So you can do this pretty quickly, and you can multitask too while you're doing it. Can we charge for the assessment? This is tough. I have seen some publications that say that you can use a CPC code for a non-diagnostic abdominal exam, and some of the costs was anywhere from like $43 to like $117. However, I don't know. I don't know what insurance companies would necessarily say about that. I know that currently in Canada they use the ultrasound like they use their stethoscope. It's really an assessment tool, but maybe down the line this is something that does occur that we charge for the assessment if they meet certain indications for it. What are the legal issues surrounding this? I am not an attorney, but I'll tell you two things. One, your verbiage. It's never no risk. It's low risk, and it's high risk. And another limitation to gastric ultrasound is that it doesn't factor in the acidity of your gastric contents. So you can still aspirate with less than 0.4 mLs per kilogram. So again, it fails to tell you the type of acidity that you're dealing with in the stomach. Conclusion, thanks for coming. I really hope that you maybe take a point of care ultrasound class. I hope you scan each other in the department and teach each other. I hope that our programs get on board in adding it to the curriculum because it was added to the COA doctoral standards. So there's no minimum requirements for our students to do point of care ultrasound before they take boards. However, I think because they added it, it's just a matter of time before we see techniques needing to be minimum requirements needing to be met. These are my three monkeys. I haven't scanned them yet, but maybe I'll do that when I get home. I wish you all happy scanning, and please feel free to contact me with any comments or questions. If we have a minute, I'm happy to field any questions. But here are my email addresses, my school and my work email. So thank you, everyone, for coming. Thank you.

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