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Milad N, Fantauzzi MF, McGrath JJ, Cass SP, Thayaparan D, Wang P, Afkhami S, Aguiar JA, Ask K, Doxey AC, Stampfli MR, Hirota JA. Cannabis smoke suppresses antiviral immune responses to influenza A in mice. ERJ Open Res 2023; 9:00219-2023. [PMID: 38020563 PMCID: PMC10680033 DOI: 10.1183/23120541.00219-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/31/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale Despite its increasingly widespread use, little is known about the impact of cannabis smoking on the response to viral infections like influenza A virus (IAV). Many assume that cannabis smoking will disrupt antiviral responses in a manner similar to cigarette smoking; however, since cannabinoids exhibit anti-inflammatory effects, cannabis smoke exposure may impact viral infection in distinct ways. Methods Male and female BALB/c mice were exposed daily to cannabis smoke and concurrently intranasally instilled with IAV. Viral burden, inflammatory mediator levels (multiplex ELISA), lung immune cells populations (flow cytometry) and gene expression patterns (RNA sequencing) were assessed in the lungs. Plasma IAV-specific antibodies were measured via ELISA. Results We found that cannabis smoke exposure increased pulmonary viral burden while decreasing total leukocytes, including macrophages, monocytes and dendritic cell populations in the lungs. Furthermore, infection-induced upregulation of certain inflammatory mediators (interferon-γ and C-C motif chemokine ligand 5) was blunted by cannabis smoke exposure, which in females was linked to the transcriptional downregulation of pathways involved in innate and adaptive immune responses. Finally, plasma levels of IAV-specific IgM and IgG1 were significantly decreased in cannabis smoke-exposed, infected mice compared to infected controls, only in female mice. Conclusions Overall, cannabis smoke exposure disrupted host-defence processes, leading to increased viral burden and dampened inflammatory signalling. These results suggest that cannabis smoking is detrimental to the maintenance of pulmonary homeostasis during viral infection and highlight the need for data regarding the impact on immune competency in humans.
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Affiliation(s)
- Nadia Milad
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
- These authors contributed equally to the studies and manuscript
| | - Matthew F. Fantauzzi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
- These authors contributed equally to the studies and manuscript
| | - Joshua J.C. McGrath
- Drukier Institute for Children's Health, Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Steven P. Cass
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Danya Thayaparan
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Peiyao Wang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Sam Afkhami
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | | | - Kjetil Ask
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Andrew C. Doxey
- Department of Biology, University of Waterloo, Waterloo, ON, Canada
| | - Martin R. Stampfli
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
| | - Jeremy A. Hirota
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Firestone Institute for Respiratory Health – Division of Respirology, Department of Medicine, McMaster University, Hamilton, ON, Canada
- McMaster Immunology Research Centre, McMaster University, Hamilton, ON, Canada
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2
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Gazarov EA, Zequeira S, Senetra AS, Howard J, Sharma A, McCurdy CR, Lewis J, Bizon JL, Setlow B. Pharmacokinetics of delta-9-tetrahydrocannabinol following acute cannabis smoke exposure in mice; effects of sex, age, and strain. Front Pharmacol 2023; 14:1227220. [PMID: 37701025 PMCID: PMC10493391 DOI: 10.3389/fphar.2023.1227220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/08/2023] [Indexed: 09/14/2023] Open
Abstract
Increased use of cannabis and cannabinoids for recreational and medical purposes has led to a growth in research on their effects in animal models. The majority of this work has employed cannabinoid injections; however, smoking remains the most common route of cannabis consumption. To better model real-world cannabis use, we exposed mice to cannabis smoke to establish the pharmacokinetics of Δ9THC and its metabolites in plasma and brain. To determine the time course of Δ9THC and two major metabolites [11-hydroxy-delta-9-tetrahydrocannabinol (11-OH-THC) and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (11-COOH-THC)], male and female C57BL/6J mice were exposed to smoke from sequentially burning 5 cannabis cigarettes. Following smoke exposure, trunk blood and brains were collected at 6 time points (10-240 min). Plasma and brain homogenates were analyzed for Δ9THC and metabolites using a validated ultraperformance liquid chromatography-tandem mass spectrometry method. To assess effects of age, sex, and mouse strain, we exposed mice of four strains (C57BL/6J, FVB, Swiss Webster, and 129S6/SvEv, aged 4-24 months) to cannabis using the same smoke regimen. Samples were collected 10 and 40 min following exposure. Lastly, to assess effects of dose, C57BL/6J mice were exposed to smoke from burning 3 or 5 cannabis cigarettes, with samples collected 40 min following exposure. The pharmacokinetic study revealed that maximum plasma Δ9THC concentrations (Cmax) were achieved at 10 and 40 min for males and females, respectively, while Cmax for brain Δ9THC was observed at 20 and 40 min for males and females, respectively. There were no age or strain differences in plasma Δ9THC concentrations at 10 or 40 min; however, 129S6/SvEv mice had significantly higher brain Δ9THC concentrations than FVB mice. Additionally, 3 cigarettes produced significantly lower plasma 11-COOH-THC concentrations compared to 5 cigarettes, although dose differences were not evident in plasma or brain concentrations of Δ9THC or 11-OH-THC. Across all experiments, females had higher levels of 11-COOH-THC in plasma compared to males. The results reveal robust sex differences in Δ9THC pharmacokinetics, and lay the groundwork for future studies using mice to model the pharmacodynamics of smoked cannabis.
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Affiliation(s)
- Emely A. Gazarov
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Sabrina Zequeira
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
| | | | - John Howard
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
| | - Abhisheak Sharma
- Department of Pharmaceutics, University of Florida, Gainesville, FL, United States
- Center for Addiction Research and Education, University of Florida, Gainesville, FL, United States
| | - Christopher R. McCurdy
- Department of Pharmaceutics, University of Florida, Gainesville, FL, United States
- Center for Addiction Research and Education, University of Florida, Gainesville, FL, United States
- Department of Medicinal Chemistry, University of Florida, Gainesville, FL, United States
| | - Jada Lewis
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
| | - Jennifer L. Bizon
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
- Center for Addiction Research and Education, University of Florida, Gainesville, FL, United States
| | - Barry Setlow
- Department of Neuroscience, University of Florida, Gainesville, FL, United States
- Department of Psychiatry, University of Florida, Gainesville, FL, United States
- Center for Addiction Research and Education, University of Florida, Gainesville, FL, United States
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3
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Haidar Z, Traboulsi H, Eidelman DH, Baglole CJ. Differential inflammatory profile in the lungs of mice exposed to cannabis smoke with varying THC:CBD ratio. Arch Toxicol 2023; 97:1963-1978. [PMID: 37179517 PMCID: PMC10183104 DOI: 10.1007/s00204-023-03514-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
Cannabis contains cannabinoids including Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC causes the psychoactive effects of cannabis, and both THC and CBD are thought to be anti-inflammatory. Cannabis is typically consumed by inhaling smoke that contains thousands of combustion products that may damage the lungs. However, the relationship between cannabis smoke exposure and alterations in respiratory health is poorly defined. To address this gap in knowledge, we first developed a mouse model of cannabis smoke exposure using a nose-only rodent inhalation exposure system. We then tested the acute effects of two dried cannabis products that differ substantially in their THC-CBD ratio: Indica-THC dominant (I-THC; 16-22% THC) and Sativa-CBD dominant (S-CBD; 13-19% CBD). We demonstrate that this smoke exposure regime not only delivers physiologically relevant levels of THC to the bloodstream, but that acute inhalation of cannabis smoke modulates the pulmonary immune response. Cannabis smoke decreased the percentage of lung alveolar macrophages but increased lung interstitial macrophages (IMs). There was also a decrease in lung dendritic cells as well as Ly6Cintermediate and Ly6Clow monocytes, but an increase in lung neutrophils and CD8+ T cells. These immune cell changes were paralleled with changes in several immune mediators. These immunological modifications were more pronounced when mice were exposed to S-CBD compared to the I-THC variety. Thus, we show that acute cannabis smoke differentially affects lung immunity based on the THC:CBD ratio, thereby providing a foundation to further explore the effect of chronic cannabis smoke exposures on pulmonary health.
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Affiliation(s)
- Zahraa Haidar
- Research Institute of the McGill University Health Centre, 1001 Decarie Blvd (EM22248), Montreal, QC, H4A3J1, Canada
- Meakins-Christie Laboratories, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Hussein Traboulsi
- Research Institute of the McGill University Health Centre, 1001 Decarie Blvd (EM22248), Montreal, QC, H4A3J1, Canada
- Meakins-Christie Laboratories, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - David H Eidelman
- Research Institute of the McGill University Health Centre, 1001 Decarie Blvd (EM22248), Montreal, QC, H4A3J1, Canada
- Meakins-Christie Laboratories, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Carolyn J Baglole
- Research Institute of the McGill University Health Centre, 1001 Decarie Blvd (EM22248), Montreal, QC, H4A3J1, Canada.
- Meakins-Christie Laboratories, Montreal, QC, Canada.
- Department of Medicine, McGill University, Montreal, QC, Canada.
- Department of Pathology, McGill University, Montreal, QC, Canada.
- Department of Pharmacology & Therapeutics, McGill University, Montreal, QC, Canada.
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4
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Preteroti M, Wilson ET, Eidelman DH, Baglole CJ. Modulation of pulmonary immune function by inhaled cannabis products and consequences for lung disease. Respir Res 2023; 24:95. [PMID: 36978106 PMCID: PMC10043545 DOI: 10.1186/s12931-023-02399-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
The lungs, in addition to participating in gas exchange, represent the first line of defense against inhaled pathogens and respiratory toxicants. Cells lining the airways and alveoli include epithelial cells and alveolar macrophages, the latter being resident innate immune cells important in surfactant recycling, protection against bacterial invasion and modulation of lung immune homeostasis. Environmental exposure to toxicants found in cigarette smoke, air pollution and cannabis can alter the number and function of immune cells in the lungs. Cannabis (marijuana) is a plant-derived product that is typically inhaled in the form of smoke from a joint. However, alternative delivery methods such as vaping, which heats the plant without combustion, are becoming more common. Cannabis use has increased in recent years, coinciding with more countries legalizing cannabis for both recreational and medicinal purposes. Cannabis may have numerous health benefits owing to the presence of cannabinoids that dampen immune function and therefore tame inflammation that is associated with chronic diseases such as arthritis. The health effects that could come with cannabis use remain poorly understood, particularly inhaled cannabis products that may directly impact the pulmonary immune system. Herein, we first describe the bioactive phytochemicals present in cannabis, with an emphasis on cannabinoids and their ability to interact with the endocannabinoid system. We also review the current state-of-knowledge as to how inhaled cannabis/cannabinoids can shape immune response in the lungs and discuss the potential consequences of altered pulmonary immunity. Overall, more research is needed to understand how cannabis inhalation shapes the pulmonary immune response to balance physiological and beneficial responses with potential deleterious consequences on the lungs.
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Affiliation(s)
- Matthew Preteroti
- Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, 1001 Decarie Blvd., Montreal, QC, H4A 3J1, Canada
- Department of Pathology, McGill University, Montreal, QC, Canada
| | - Emily T Wilson
- Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, 1001 Decarie Blvd., Montreal, QC, H4A 3J1, Canada
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
| | - David H Eidelman
- Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, 1001 Decarie Blvd., Montreal, QC, H4A 3J1, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Carolyn J Baglole
- Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, 1001 Decarie Blvd., Montreal, QC, H4A 3J1, Canada.
- Department of Pathology, McGill University, Montreal, QC, Canada.
- Department of Medicine, McGill University, Montreal, QC, Canada.
- Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada.
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Aloufi N, Namkung Y, Traboulsi H, Wilson ET, Laporte SA, Kaplan BLF, Ross MK, Nair P, Eidelman DH, Baglole CJ. Standardized Cannabis Smoke Extract Induces Inflammation in Human Lung Fibroblasts. Front Pharmacol 2022; 13:852029. [PMID: 35418857 PMCID: PMC8996138 DOI: 10.3389/fphar.2022.852029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/25/2022] [Indexed: 11/18/2022] Open
Abstract
Cannabis (marijuana) is the most commonly used illicit product in the world and is the second most smoked plant after tobacco. There has been a rapid increase in the number of countries legalizing cannabis for both recreational and medicinal purposes. Smoking cannabis in the form of a joint is the most common mode of cannabis consumption. Combustion of cannabis smoke generates many of the same chemicals as tobacco smoke. Although the impact of tobacco smoke on respiratory health is well-known, the consequence of cannabis smoke on the respiratory system and, in particular, the inflammatory response is unclear. Besides the combustion products present in cannabis smoke, cannabis also contains cannabinoids including Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD). These compounds are hydrophobic and not present in aqueous solutions. In order to understand the impact of cannabis smoke on pathological mechanisms associated with adverse respiratory outcomes, the development of in vitro surrogates of cannabis smoke exposure is needed. Therefore, we developed a standardized protocol for the generation of cannabis smoke extract (CaSE) to investigate its effect on cellular mechanisms in vitro. First, we determined the concentration of Δ9-THC, one of the major cannabinoids, by ELISA and found that addition of methanol to the cell culture media during generation of the aqueous smoke extract significantly increased the amount of Δ9-THC. We also observed by LC-MS/MS that CaSE preparation with methanol contains CBD. Using a functional assay in cells for CB1 receptors, the major target of cannabinoids, we found that this CaSE contains Δ9-THC which activates CB1 receptors. Finally, this standardized preparation of CaSE induces an inflammatory response in human lung fibroblasts. This study provides an optimized protocol for aqueous CaSE preparation containing biologically active cannabinoids that can be used for in vitro experimentation of cannabis smoke and its potential impact on various indices of pulmonary health.
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Affiliation(s)
- Noof Aloufi
- Meakins-Christie Laboratories, Montreal, QC, Canada.,Translational Research in Respiratory Diseases Program at the Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Pathology, McGill University, Montreal, QC, Canada.,Department of Medical Laboratory Technology, Applied Medical Science, Taibah University, Medina, Saudi Arabia
| | - Yoon Namkung
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Hussein Traboulsi
- Meakins-Christie Laboratories, Montreal, QC, Canada.,Translational Research in Respiratory Diseases Program at the Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada
| | - Emily T Wilson
- Meakins-Christie Laboratories, Montreal, QC, Canada.,Translational Research in Respiratory Diseases Program at the Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
| | - Stephane A Laporte
- Department of Medicine, McGill University, Montreal, QC, Canada.,Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
| | - Barbara L F Kaplan
- Department of Comparative Biomedical Sciences, Mississippi State University, Mississippi State, MS, United States
| | - Matthew K Ross
- Department of Comparative Biomedical Sciences, Mississippi State University, Mississippi State, MS, United States
| | - Parameswaran Nair
- Department of Medicine, McMaster University and St Joseph's Healthcare, Hamilton, ON, Canada
| | - David H Eidelman
- Meakins-Christie Laboratories, Montreal, QC, Canada.,Translational Research in Respiratory Diseases Program at the Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada
| | - Carolyn J Baglole
- Meakins-Christie Laboratories, Montreal, QC, Canada.,Translational Research in Respiratory Diseases Program at the Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Department of Pathology, McGill University, Montreal, QC, Canada.,Department of Medicine, McGill University, Montreal, QC, Canada.,Department of Pharmacology and Therapeutics, McGill University, Montreal, QC, Canada
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Why Do Marijuana and Synthetic Cannabimimetics Induce Acute Myocardial Infarction in Healthy Young People? Cells 2022; 11:cells11071142. [PMID: 35406706 PMCID: PMC8997492 DOI: 10.3390/cells11071142] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 12/19/2022] Open
Abstract
The use of cannabis preparations has steadily increased. Although cannabis was traditionally assumed to only have mild vegetative side effects, it has become evident in recent years that severe cardiovascular complications can occur. Cannabis use has recently even been added to the risk factors for myocardial infarction. This review is dedicated to pathogenetic factors contributing to cannabis-related myocardial infarction. Tachycardia is highly important in this respect, and we provide evidence that activation of CB1 receptors in brain regions important for cardiovascular regulation and of presynaptic CB1 receptors on sympathetic and/or parasympathetic nerve fibers are involved. The prototypical factors for myocardial infarction, i.e., thrombus formation and coronary constriction, have also been considered, but there is little evidence that they play a decisive role. On the other hand, an increase in the formation of carboxyhemoglobin, impaired mitochondrial respiration, cardiotoxic reactions and tachyarrhythmias associated with the increased sympathetic tone are factors possibly intensifying myocardial infarction. A particularly important factor is that cannabis use is frequently accompanied by tobacco smoking. In conclusion, additional research is warranted to decipher the mechanisms involved, since cannabis use is being legalized increasingly and Δ9-tetrahydrocannabinol and its synthetic analogue nabilone are indicated for the treatment of various disease states.
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Laudanski K, Wain J. Considerations for Cannabinoids in Perioperative Care by Anesthesiologists. J Clin Med 2022; 11:jcm11030558. [PMID: 35160010 PMCID: PMC8836924 DOI: 10.3390/jcm11030558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 02/07/2023] Open
Abstract
Increased usage of recreational and medically indicated cannabinoid compounds has been an undeniable reality for anesthesiologists in recent years. These compounds’ complicated pharmacology, composition, and biological effects result in challenging issues for anesthesiologists during different phases of perioperative care. Here, we review the existing formulation of cannabinoids and their biological activity to put them into the context of the anesthesia plan execution. Perioperative considerations should include a way to gauge the patient’s intake of cannabinoids, the ability to gain consent properly, and vigilance to the increased risk of pulmonary and airway problems. Intraoperative management in individuals with cannabinoid use is complicated by the effects cannabinoids have on general anesthetics and depth of anesthesia monitoring while simultaneously increasing the potential occurrence of intraoperative hemodynamic instability. Postoperative planning should involve higher vigilance to the risk of postoperative strokes and acute coronary syndromes. However, most of the data are not up to date, rending definite conclusions on the importance of perioperative cannabinoid intake on anesthesia management difficult.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: (K.L.); (J.W.)
| | - Justin Wain
- School of Osteopathic Medicine, Campbell University, Buies Creek, NC 27506, USA
- Correspondence: (K.L.); (J.W.)
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