Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), including semaglutide (Wegovy®), are increasingly used for weight management in both adult and pediatric populations. Their mechanism of delayed gastric emptying raises concern for aspiration during anesthesia, yet current fasting guidelines provide limited direction for these patients. We present the case of a 14-year-old female patient with autism, developmental delay, and obesity managed with semaglutide who presented for esophagogastroduodenoscopy and colonoscopy. Despite holding semaglutide for 12 days, completing bowel preparation, and fasting from solids for 32 hours and clear liquids for 10 hours, preoperative gastric point-of-care ultrasound revealed a distended antrum containing fluid and particulate matter consistent with a full stomach. After multidisciplinary discussion and informed consent, the procedure proceeded with rapid sequence induction and endotracheal intubation to mitigate aspiration risk. Endoscopy confirmed substantial residual gastric contents exceeding 200 mL, though the procedure and anesthetic course were uneventful. This case underscores that standard fasting protocols may not ensure gastric emptying in patients on GLP-1 RA therapy, particularly during medication up-titration or in those with coexisting gastrointestinal motility disorders. Point-of-care gastric ultrasound proved valuable for individualized risk assessment and anesthetic planning. As the use of GLP-1 RAs expands, anesthesia teams should maintain heightened vigilance, consider extended fasting or gastric ultrasound when feasible, and engage in shared decision-making regarding perioperative management. Further research and updated guidelines are needed to define evidence-based fasting intervals and anesthetic strategies for this growing patient population.
