Cannabis and Cannabinoids in the Perioperative Period

Association of cannabis use with major cardiovascular and cerebrovascular events after surgery or interventional procedures

BACKGROUND AND OBJECTIVES

Previous studies reported a predisposition to major adverse cardiovascular or cerebrovascular events (MACCE) in patients consuming cannabis, which might be exacerbated by interventional or surgical procedures. This study investigated the association of nonmedical cannabis use with MACCE after interventional procedures or surgery.

METHODS

288,923 adult patients undergoing noncardiac surgery between 2008 and 2020 at a tertiary academic hospital in Massachusetts, United States, were included. The exposure was nonmedical use of cannabis, differentiated into ongoing self-reported recreational use or a diagnosis of cannabis use disorder. The primary outcome was MACCE, defined as ischemic stroke, cardiac arrest, acute heart failure, myocardial infarction, or revascularization within 1 year.

RESULTS

Patients with a diagnosis of cannabis use disorder had a higher risk of MACCE (adjusted odds ratio 1.26; 95%CI 1.05-1.51; p = .02). For recreational users, this was dependent on the patient's baseline cardiac risk, based on the revised cardiac risk index (RCRI) class: among patients at high cardiac risk (RCRI class III/IV), recreational cannabis use was associated with increased risk (adjusted odds ratio 1.41; 1.15-1.74; p = .001), while there was no association among patients with a low RCRI class (I/II; adjusted odds ratio 0.87; 0.75-1.02; p = .09).

DISCUSSION AND CONCLUSIONS

Patients with a diagnosed cannabis use disorder are at increased risk of post-procedural MACCE, while for recreational users, this association was dependent on patients' baseline cardiac risk.

SCIENTIFIC SIGNIFICANCE

This study demonstrates the association between cannabis use and MACCE differentiated by type of use and depending on baseline cardiac risk.

Enhancing the Preanesthesia Evaluation: Consensus Development of the Cannabis Use and Behaviors Assessment Tool (CUBAT)

PURPOSE

This project aimed to develop an evidence-based preanesthesia cannabis use assessment tool to acquire complete and accurate patient history and develop a best-informed, individualized anesthesia and analgesia care plan.

DESIGN

Modified Delphi.

METHODS

Using an evidence synthesis and multistage, modified Delphi process, eight experts from across the United States developed a consensus-based tool to aid in developing a best-informed, individualized plan for anesthesia and analgesia care.

FINDINGS

Two survey rounds integrated informed evidence-based tool revisions. The final tool included instructions for use, a glossary of terms, and seven key assessment items aimed at gathering the most influential information regarding cannabis use.

CONCLUSIONS

The Cannabis Use and Behaviors Assessment Tool is a first-of-its-kind tool providing an essential framework for preanesthesia cannabis use assessment.

Quantitative Analysis of Propofol Dosage in Cannabis Users: A Systematic Review and Meta-Analysis

Background: Rising cannabis use poses significant challenges in the administration of general anesthetics, particularly propofol, due to potential alterations in pharmacodynamics caused by tetrahydrocannabinol and its interactions with central nervous system receptors. This systematic review and meta-analysis aims to consolidate the existing literature to quantify propofol requirements in cannabis users, highlighting the complex relationship between cannabis use and anesthetic management. Methods: A systematic search of English-language literature was conducted to identify studies with data on propofol dosing in adult cannabis users. Propofol requirements were defined as the total intraoperative dose needed to achieve and maintain adequate sedation or anesthesia, assessed using parameters like monitoring and procedural tolerance. A random-effects model was used with DerSimonian-Laird estimations for pooled effect sizes and 95% confidence intervals. Heterogeneity was assessed using I2 and Cochran's Q statistics, and sensitivity analysis was conducted by grouping publications by design, size, and quality. Results: Eight qualified studies were identified with 2268 patients included. Patients who used cannabis were typically younger and more likely to smoke tobacco than non-users. Propofol requirements were significantly higher in cannabis users, who required an average additional dose of 47.33 mg compared to non-users. Subgroup analyses revealed that cannabis users undergoing general anesthesia needed an additional 30.57 mg intraoperatively, while those undergoing sedation for endoscopic procedures required an additional 53.02 mg. Conclusions: These results underscore the need for personalized anesthetic plans to accommodate physiological variations in cannabis users. However, the lack of standardized definitions for propofol requirements and the heterogeneity across studies necessitate caution in interpretation. The observed increase in propofol requirements suggests altered central nervous system sensitivities and receptor changes in cannabis users, emphasizing the need for further research to establish clear definitions, elucidate underlying mechanisms, and refine clinical guidelines for anesthetic management in this population.

The impact of cannabis use disorder on urologic oncologic surgery morbidity, length of stay, and inpatient cost: analysis of the National Inpatient Sample from 2003 to 2014

PURPOSE

This study examined the impact of cannabis use disorder (CUD) on inpatient morbidity, length of stay (LOS), and inpatient cost (IC) of patients undergoing urologic oncologic surgery.

METHODS

The National Inpatient Sample (NIS) from 2003 to 2014 was analyzed for patients undergoing prostatectomy, nephrectomy, or cystectomy (n = 1,612,743). CUD was identified using ICD-9 codes. Complex-survey procedures were used to compare patients with and without CUD. Inpatient major complications, high LOS (4th quartile), and high IC (4th quartile) were examined as endpoints. Univariable and multivariable analysis (MVA) were performed to compare groups.

RESULTS

The incidence of CUD increased from 51 per 100,000 admissions in 2003 to 383 per 100,000 in 2014 (p < 0.001). Overall, 3,503 admissions had CUD. Patients with CUD were more frequently younger (50 vs. 61), male (86% vs. 78.4%), Black (21.7% vs. 9.2%), and had 1st quartile income (36.1% vs. 20.6%); all p < 0.001. CUD had no impact on any complication rates (all p > 0.05). However, CUD patients had higher LOS (3 vs. 2 days; p < 0.001) and IC ($15,609 vs. $12,415; p < 0.001). On MVA, CUD was not an independent predictor of major complications (p = 0.6). Conversely, CUD was associated with high LOS (odds ratio (OR) 1.31; 95% CI 1.08-1.59) and high IC (OR 1.33; 95% CI 1.12-1.59), both p < 0.01.

CONCLUSION

The incidence of CUD at the time of urologic oncologic surgery is increasing. Future research should look into the cause of our observed phenomena and how to decrease LOS and IC in CUD patients.

Use of herbal medication in the perioperative period: Potential adverse drug interactions

Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.

Cannabinoids for Acute Pain Management: Approaches and Rationale

PURPOSE OF THE REVIEW

Acute pain management remains a challenge and postoperative pain is often undermanaged despite many available treatment options, also including cannabinoids.

RECENT FINDINGS

In the light of the opioid epidemic, there has been growing interest in alternative care bundles for pain management, including cannabinoids as potential treatment to decrease opioid prescribing. Despite the lack of solid evidence on the efficacy of cannabinoids, their use among patients with pain, including those using opioids, is currently increasing. This use is supported by data suggesting that cannabinoids could potentially contribute to a better pain management and to a reduction in opioid doses while maintaining effective analgesia with minimum side effects. The scientific basis for supporting the use of cannabis is extensive, although it does not necessarily translate into relevant clinical outcomes. The use of cannabinoids in acute pain did not always consistently show statistically significant results in improving acute pain. Large randomized, controlled trials evaluating diverse cannabis extracts are needed in different clinical pain populations to determine safety and efficacy.

Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review

Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.

Is Recreational Marijuana Use Associated With Changes in the Vital Signs or Anesthetic Requirements During Intravenous Sedation?

PURPOSE

The prevalence of tetrahydrocannabinol (THC) use is increasing in the general population due to its increased availability, legality, and cultural acceptability. The purpose of the current study was to measure the association of THC use on the vital signs and anesthetic requirements during intravenous (IV) sedation procedures in recreational marijuana users.

METHODS

A retrospective cohort study was performed. A study sample was chosen from July 2018 to May 2022 based on the following inclusion criteria: patients who underwent toxicology screening due to their history of recent drug use and received IV sedation. The predictor variable of the present study is THC status grouped into THC+ and THC-. THC status was established using urine toxicology. Patients who screened positive for THC were coded THC+. Patients who screened negative for THC were coded THC-. Primary outcome variable was changes in vital signs, including mean arterial pressure (MAP), heart rate (HR), and respiratory rate (RR) during IV sedation procedures in THC+ and THC- groups. Secondary outcome variable was difference in medication (midazolam, fentanyl, propofol, and ketamine) requirements in THC+ and THC- groups. Covariates included age, gender, race, weight, duration of surgery, smoking history, and alcohol use, data on psychiatric diagnosis and psychiatric medications. Descriptive statistics and 2-sample t test were calculated. Statistical significance was set at P < .05.

RESULTS

In total, 53 patients met the inclusion criteria and were included in the study, with 27 patients in the THC+ group and 26 patients in the THC- group. There were no significant statistical differences in the MAP_%, HR_%, and RR_% at T₅, T₁₀, T₂₀, and T₃₀ between the THC+ and THC- groups. When comparing THC+ and THC- groups, in bivariate analyses, the THC+ group required, on average, higher doses of fentanyl [83.82 mcg compared to 65 mcg (P = .02)] and propofol [70 mg compared to 45.26 mg (P = .03)] during IV sedation. However, after adjusting the effect of age, gender, and weight, THC had no significant effect on midazolam (P-value = .28), fentanyl (P-value = .12), propofol (P-value = .06) and ketamine (P-value = .86) requirements.

CONCLUSIONS

These findings suggest there are no differences in vital signs or anesthetic requirements between the THC+ and THC- groups.