Journal Club: GLP-1 Agonists and Aspiration (GLIMPSE)

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Journal Club: GLP-1 Agonists and Aspiration (GLIMPSE)

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Recorded minutes after the live launch at Annual Congress 2026, and published the same day the paper appears in Anaesthesia. GLIMPSE — the GLP-1 receptor agonist Management in the Peri-operative Setting project — is a national, prospective, multicentre cohort study delivered through the UK resident research networks across all four nations, and it is the largest thing anyone has done on this question. Mike and Calum take it apart the way they did ITACS: the question, the methods, the results, the critique. Then the half that wasn't in the room — what it means for cardiothoracic anaesthesia and intensive care. Two numbers to start. One in 36 patients presenting for anaesthesia in the UK is taking a GLP-1 receptor agonist. And in those patients, the incidence of pulmonary aspiration or regurgitation was 1 in 71, against 1 in 802 in everyone else — an odds ratio of about 11. Then the work of deciding how much of that to believe. The framing that governs everything: the primary outcome is a prevalence, not a comparison. GLIMPSE was designed to answer "how many?" The aspiration finding is a secondary outcome, and every conclusion about the odds ratio has to sit inside that. We cover the design — each site choosing its own fortnight, screening every patient's drug history — the exclusions, the deliberate discarding of twelve sites that screened fewer than three quarters of their eligible patients, and the 97% screening rate that makes this a remarkably complete national snapshot. The prevalence findings are more interesting than the headline. Between institutions, use ranged from 0.4% to 7.8% — a twenty-fold difference — so the national average is close to useless for planning your own list. Tirzepatide accounts for 70% and semaglutide 26%, and this is now predominantly a weight-loss population rather than a diabetes one. And the number that should change your practice this week: 41% obtained the drug from somewhere that is neither a GP nor a hospital specialist. It will not be on the GP summary, the discharge letter or the drug chart. It is only there if somebody asks the patient directly, by name. Management was highly variable. Thirty per cent were asked to stop, most for 8–14 days — consistent with "stop it for a week", which the paper quietly demolishes: with half-lives of five and seven days, five half-lives means 25 and 35 days. A week does not eliminate the drug, and national consensus guidance says to continue it anyway. Meanwhile gastric ultrasound — the one bedside test that answers precisely the question being asked — was used in 1.3% of patients. The safety finding gets the full appraisal, including the qualifier that changes how you read it: of the 19 events in the exposed group, all 19 involved regurgitation and only two reached the lung, which suggests the intubation, head-up positioning and pre-oxygenation were doing their job. And the finding we'd most like to change practice: more than half the events happened at emergence, not induction. The critique covers association without any ability to adjust for confounding, observer bias inflating the ratio from both ends (with the NAP7 cross-check that partly defends it), small event numbers driving a large effect, and generalisability. The strengths get their due too. Then the cardiothoracic half, which the paper does not address. Why our prevalence is probably higher than the national figure. Why the months between assessment and surgery make the drug-history gap worse for us. Why emergence happening on the intensive care unit, hours later, makes this a handover problem as much as an airway problem.What it means that we put a probe into the stomach of nearly every patient we anaesthetise — and that we already own the skill that was used in 1% of cases nationally. The double-lumen tube versus tube-exchange dilemma, taken from a real case in the paper. The conflict between a rapid sequence induction and haemodynamic stability in critical aortic stenosis. Why stopping the drug costs our patients more, through hyperglycaemia and sternal wound infection. And the exclusion that matters most to us: GLIMPSE excluded patients whose airway management began elsewhere — ICU transfers explicitly — so our sickest patients are entirely outside the dataset. Chapters (00:00) Cold open — outside Hall 1A, minutes after the launch(00:50) The two headline numbers(01:30) Why the question needed asking(02:40) Methods: design, sites and the fortnight(03:30) The exclusions — including ICU transfers(04:10) The primary outcome is a prevalence, not a comparison(05:00) Powering, and discarding twelve sites on purpose(05:50) One in 36 — and the twenty-fold variation between hospitals(07:00) Which drugs, and why people were taking them(07:40) Where they got them: the 41% that isn't on any record(08:40) What clinicians did: stopping for a week(09:40) Why a week is pharmacologically meaningless(10:30) Airway management — and gastric ...

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