Elective Cholecystectomy in a Poorly Controlled Diabetic Taking a GLP-1 Agonist

Address before transport to the OR, in this order:

1. Aspiration risk (most time-critical). Semaglutide delays gastric emptying; the last dose was only 3 days ago (weekly dosing, so not a full hold), and he has active nausea and vomiting with a glucose of 212. NPO status does not guarantee an empty stomach. This changes the airway plan, so anesthesia must know now, not in the room. Options include point-of-care gastric ultrasound or a full-stomach induction strategy (rapid sequence).
2. Potassium 3.4 mEq/L. Hypokalemia in a patient about to be anesthetized and insufflated warrants notification and repletion per order; it is a modifiable arrhythmia risk and should be corrected before an elective case.
3. Glycemic control. HbA1c 9.4% and glucose 212 predict perioperative hyperglycemia, impaired wound healing, and higher SSI risk. This is a reason to escalate to the surgeon and anesthesia for a glucose management plan and a documented discussion of whether to proceed or reschedule, not a number the CSFA decides alone.
4. Allergy clarification (see next task) and mild tachycardia/hypertension, which should be interpreted in light of the above rather than dismissed.

Reasoning principle: the CSFA does not "clear" patients. The role is to surface and escalate findings with a recommended plan so the responsible physician can decide.

The label is unverified and the reported reaction is low-risk, but it cannot simply be ignored or overridden by the CSFA.

• Obtain the history now: what the rash looked like, how soon after the dose it appeared, whether there was swelling, hives, breathing difficulty, or hospitalization, and how long ago. A remote, isolated, non-blistering rash has a low likelihood of true IgE-mediated allergy.
• Route the information to the prescriber and pharmacy. Under most institutional protocols a remote benign rash does not preclude cefazolin, since cephalosporin cross-reactivity is low and is driven by shared side chains, not the beta-lactam ring alone. The surgeon, with pharmacy input, makes that call and it must be documented.
• Do not let the clarification delay prophylaxis. Prophylaxis should be infusing within 60 minutes before incision (within 120 minutes for vancomycin/fluoroquinolones). If clarification cannot be completed in time, an appropriate non-beta-lactam alternative per protocol is used and the reason is documented.
• Update the record with the specific reaction rather than leaving "PCN allergy" as a permanent, uninformative label, and refer for allergy evaluation after discharge.

Reasoning principle: an unverified allergy label is a safety and quality problem in both directions - it can cause anaphylaxis if wrong and inferior prophylaxis or unnecessary broad-spectrum agents if unchallenged.

Verbal handoff (SBAR-style, concise):

• Situation: Elective lap chole, first case, patient with T2DM on weekly semaglutide.
• Background: Last dose 3 days ago; nausea and one episode of vomiting this morning; NPO since midnight; glucose 212; potassium 3.4; HR 96.
• Assessment: Possible retained gastric contents - GLP-1 receptor agonists delay gastric emptying and NPO time does not reliably empty the stomach.
• Recommendation: Please evaluate for gastric ultrasound or plan rapid-sequence induction/full-stomach precautions; potassium repletion is pending.

Document, factually and time-stamped: last dose date and drug, the reported nausea/vomiting, NPO start time, who was notified (name/role) and when, and what was requested. Avoid interpretive language like "patient is fine."

Reasoning principle: the value of the handoff is that it transfers a risk with a proposed plan, not just a data point. A vomiting patient with a GLP-1 on board is a different airway conversation than an asymptomatic one, and documenting the notification protects everyone if the plan is not acted on.