Type 2 diabetes on a GLP-1 agonist and SGLT2 inhibitor for laparoscopic colectomy58-year-old man, 96 kg, for elective laparoscopic right hemicolectomy on an enhanced-recovery pathway

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 58-year-old with poorly controlled type 2 diabetes and organ damage, for elective laparoscopic colectomy. Patient
   • His kidneys, nerves and likely silent coronary disease all shape this anaesthetic. Disease
   • Semaglutide delays his gastric emptying; he may aspirate even after a normal fast.
   • Empagliflozin plus fasting can tip him into ketoacidosis with a near-normal glucose.
   • His postural drop and fixed heart rate point to autonomic neuropathy: arrhythmias and hypotension under anaesthesia.

2. Prepare

   How do you prepare him for the day?

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   • HbA1c 9.4% reflects about three months of poor control, so I review heart, kidneys and nerves. (Disease)
   • Empagliflozin stops 3–4 days before surgery.
   • On the day I check his ketones and anion gap, whatever his glucose reads.
   • Glargine cut by 20%; metformin and other oral agents held that morning.
   • His early fullness raises risk: semaglutide held a week ahead if we agree to hold.
   • Because of his symptoms, a liquid diet for 24 hours beforehand.

3. Plan

   How do you run his anaesthetic and his glucose?

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   • Gastric ultrasound on the day if I'm unsure his stomach is empty. Airway
   • Solids seen, or still unsure: a rapid sequence, using rocuronium 1.2 mg/kg.
   • Long fast and long case: variable-rate insulin, with dextrose and potassium running alongside. Disease
   • Hourly glucose, with 140–180 mg/dL as his target.
   • Dexamethasone for PONV will raise his glucose because his control is poor; I treat to target.
   • Oral agents restart once he is eating a normal diet. After surgery

4. Crisis

   At induction, after propofol and before the relaxant works, gastric fluid wells up in his pharynx. SpO2 97%. What do you do?

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   • Regurgitation at induction, in a man on a GLP-1 agonist with gastroparesis. Crisis
   • Tilt him head-down and suction his pharynx at once.
   • Intubate with a cuffed tube, then suction down it on 100% oxygen. Airway
   • Bronchoscopy if particles may have gone down; no saline washout, which spreads the aspirate. Crisis
   • If his oxygenation holds, I discuss with the surgeon whether to proceed. Surgery
   • A quarter of patients who aspirate develop significant lung problems, so he's watched closely afterwards. After surgery

5. Crisis

   Five minutes after intubation his BP is 68/40, HR 98. Two ephedrine boluses have done nothing. What now?

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   • Refractory hypotension with autonomic neuropathy; indirect agents work poorly in him. (Crisis)
   • Phenylephrine 50–100 mcg, starting small because his alpha receptors may be upregulated.
   • If he stays low, noradrenaline by infusion, 0.05–0.3 mcg/kg/min.
   • Arterial line now, with fluid as needed to protect his diabetic kidneys.
   • I also exclude hypoxia from aspiration, bleeding, and anaphylaxis to the relaxant.