Endocrine · 7 min
Endocrine — last-night quick guide
Diabetes (incl GLP-1 ASA 2023), thyroid, adrenal, pheo, GLP-1 NPO.
Rule
GLP-1 ASA 2023 update
GLP-1 agonists (semaglutide, liraglutide, tirzepatide) slow gastric emptying — aspiration risk even at NPO. HOLD weekly GLP-1s 1 wk preop, daily 1 day preop. If continued + NPO unclear → 8 hr clear liquids + RSI; gastric POCUS if symptoms. Have RSI plan + suction ready.
Perioperative diabetes meds
| Drug | Day-of-surgery |
|---|---|
| Long-acting insulin (glargine, detemir, degludec) | Continue 50-80% normal dose |
| Short-acting insulin (regular, lispro) | Hold AM if NPO |
| Metformin | Hold AM (controversial — 2023 ASA softer if normal renal fx) |
| Sulfonylureas | Hold AM |
| SGLT2 (empagliflozin, dapagliflozin) | Hold 3-4 days preop — euglycemic DKA risk |
| GLP-1 agonists (semaglutide, etc) | Hold per 2023 ASA — aspiration risk |
| Insulin pump | Continue basal, suspend boluses |
Rule
Thyroid storm vs MH vs sepsis
Storm: hyperthermia + tachy/AF + GI + altered mental status; treat with PTU 200 q4h (blocks T4→T3) → iodide 1h after PTU → propranolol → hydrocortisone 100 q8h. Differs from MH: gradual onset, no rigidity, no volatile/succ trigger.
Rule
Adrenal stress dose
Patients on chronic steroids (>20 mg pred/day × 3 weeks within last year) need stress-dose for moderate-major surgery. Hydrocortisone 100 mg IV pre-induction, then 100 mg q8h × 24-48h. Minor surgery: usual home dose continues. Always continue home dose day-of.
Watch out
Pheo intraop
α-block × 2 wk preop (phenoxybenzamine 10-40 mg/day OR doxazosin) BEFORE adding β-block. Have nitroprusside + phentolamine + esmolol ready for HTN crisis with tumor manipulation. Have NE + vasopressin ready for post-vascular-ligation hypotension.