Perioperative medicine: Overview

Abstract
Background: The hyperactivity of the sympathetic nervous system after a traumatic event contributes to the development of post-traumatic stress disorder (PTSD). Polarised light stellate ganglion irradiation (PLSGI) is a non-invasive and effective physiotherapy method for regulating the sympathetic nervous system. This study aims to investigate the effects of perioperative PLSGI on PTSD and pain-related outcomes in patients undergoing emergency surgery.

Methods and analysis: This multicentre, randomised, double-blind, controlled trial will include 510 adult patients scheduled for emergency trauma surgery. Patients will be randomly assigned in a 1:1 ratio, stratified by anaesthesia type (propofol general anaesthesia or other anaesthesia), to either the PLSGI group or the control group. The PLSGI group will receive perioperative PLSGI, while the control group will receive a sham PLSGI procedure. All patients will receive multimodal analgesia, consisting of intraoperative flurbiprofen axetil, ropivacaine infiltration at the end of surgery and postoperative patient-controlled sufentanil. The primary outcome is the incidence of PTSD 1 month postoperatively. Secondary outcomes include the severity of PTSD, delayed-onset PTSD, four symptom clusters (intrusive re-experiencing symptoms, avoidance symptoms, negative alterations in cognition or mood symptoms, and hyperarousal and reactivity symptoms), severity of dissociative symptoms, the amount of emergency postoperative analgesia, heart rate variability, sleep quality, anxiety, chronic pain, postoperative opioid use (sufentanil consumption) and need for rescue analgesia. Safety outcomes include hypotension, bradycardia, hypertension, tachycardia, interventions for haemodynamic events, malignant arrhythmias, hoarseness, localised allergy or burning pain, dyspnoea and coughing while drinking. All analyses will be conducted in the modified intention-to-treat population.

Ethics and dissemination: Ethical approval was obtained from the Ethics Committee of Xuzhou Central Hospital (XZXY-LK-20210129-2023040), the Ethics Committee of Suzhou Xiangcheng People's Hospital (2023-KY-02) and the Ethics Committee of Xuzhou Renci Hospital (XZRCLL-KT-202302001). All patients will provide written informed consent. The results of this study will be published in a peer-reviewed journal.

Abstract
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are widely used for the treatment of type 2 diabetes and/or obesity. The physiological actions of endogenous GLP-1, and synthetic GLP-1RAs include inhibition of gastric emptying. This has peri-procedural implications due to the potential increased risk of retained gastric contents which may result in pulmonary aspiration. There is a need for local evidence-based guidelines to best manage patients on GLP-1RAs and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonists (GLP-1/GIPRAs) presenting for surgical and medical procedures requiring sedation or anaesthesia. A panel of experts was formed to consider the peri-procedural implications of GLP-1RA and GLP-1/GIPRA use and establish best practice recommendations based on the current evidence.We recommend that all patients should be asked about glucagon-like peptide-1 receptor agonist (GLP-1RA) and dual GLP-1 and glucose-dependent insulinotropic polypeptide receptor co-agonist (GLP-1/GIPRA) use prior to anaesthesia or sedation for surgical and endoscopic procedures and be informed of the benefits and risks. We also recommend that GLP-1RAs and GLP-1/GIPRAs be continued in the peri-procedural period. Preprocedural diet modification with a 24-h clear fluid diet, followed by standard 6-h fasting, should be recommended for all patients receiving GLP-1RAs or GLP-1/GIPRAs. In patients who have not completed or are unable to have a 24-h liquid diet, risk stratification using gastric ultrasound or minimally sedated gastroscopy to assess gastric contents is recommended, as is the use of intravenous erythromycin. We cannot currently recommend using the absence of gastrointestinal symptoms for risk stratification, nor can we recommend an adequate cessation period for GLP-1RAs and GLP-1/GIPRAs to ensure gastric emptying has returned to baseline levels. This clinical guideline, developed by multiple professional bodies, outlines current best practice recommendations for patients taking GLP-1RAs and combined GLP-1/GIPRAs who require general anaesthesia, sedation and/or endoscopic procedures. The guide provides a structure for Australian and New Zealand primary health practitioners, gastroenterologists, surgeons, endocrinologists, anaesthetists and perioperative physicians to support clinical decisions in these patients.