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Kosirog J, Bouvette C, Pannu J, Gondal J, Madhoun M. Marijuana and endoscopy: the effects of marijuana on sedation. Gastrointest Endosc 2024; 100:177-182. [PMID: 38215858 DOI: 10.1016/j.gie.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND AND AIMS Marijuana usage has increased significantly as it has become more readily available and legal, either recreationally or medicinally, in many states. It has been postulated that marijuana usage increases the amount of sedation required for procedures. However, there are minimal data defining this relationship. We aimed to establish the relationship between marijuana usage and the amount of sedation used during endoscopy. METHODS This was a single-institution prospective study of patients undergoing outpatient endoscopy (both monitored anesthesia care [MAC] and moderate sedation) at the Oklahoma City Veterans Affairs Medical Center. Marijuana usage was assessed by a voluntary de-identified pre-endoscopy survey. Information regarding sedation used, endoscopy outcomes, demographics, comorbidities, medical history, and medications used was extracted from the medical record. A univariate and stratified analysis of alcohol usage was performed. A P value of <.05 was considered to be significant. RESULTS A total of 976 patients were analyzed; 21.5% of them endorsed marijuana usage (210/976). Marijuana users were found to be younger (P = .0002), leaner (P < .0001), and less likely to have diabetes (P = .002), obstructive sleep apnea (P = .0002), and hypertension (P = .04). They were also more likely to smoke (P < .0001) and vape (P < .0001). Marijuana usage was associated with a higher requirement of sedation (fentanyl [P = .003], midazolam [P = .05], propofol [P = .02]) and higher use of adjunct sedation (diphenhydramine in moderate sedation [P = .0003]). Further multivariate analyses were performed to control for possible confounders. Marijuana usage was still deemed to be an independent predictor for high propofol use among MAC cases (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.00-3.12). Likewise, marijuana usage was found to be an independent predictor for high midazolam use (OR, 1.57; 95% CI, 1.02-2.42) and high fentanyl use (OR, 1.54; 95% CI, 0.98-2.38), but failed to reach statistical significance in the fentanyl group. CONCLUSIONS Marijuana use is associated with a significantly higher amount of sedation along with a significantly higher usage of other adjunct sedatives. A patient's marijuana history should be considered when determining the methods of sedation to be used for endoscopy.
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Affiliation(s)
- Justin Kosirog
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA; Section of Digestive Diseases and Nutrition, Department of Medicine, Oklahoma City, Oklahoma, USA
| | - Christopher Bouvette
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA; Department of Internal Medicine, Oklahoma City, Oklahoma, USA
| | - Jiteshwar Pannu
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA; Department of Internal Medicine, Oklahoma City, Oklahoma, USA
| | - Jalal Gondal
- University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Mohammad Madhoun
- Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA; Section of Digestive Diseases and Nutrition, Department of Medicine, Oklahoma City, Oklahoma, USA
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Smith LD, Pelton W, Morgan MK. Effects of Cannabis Use on Sedation Requirements for Endoscopic Procedures: A Replication Study. Gastroenterol Nurs 2024; 47:286-290. [PMID: 39087994 DOI: 10.1097/sga.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 05/01/2024] [Indexed: 08/02/2024] Open
Abstract
On July 1, 2021, cannabis became legal in Virginia for adults 21 years of age and older. Cannabis consumption may have significant implications for outcomes related to medical care, including procedural sedation. The purpose of this study was to determine whether self-reported cannabis consumption has any relationship to sedation medication requirements during endoscopic procedures. A retrospective analysis was conducted to examine two groups of surgical patients (self-reported cannabis use versus self-reported non-cannabis use) at a community hospital in the mid-Atlantic region. Results demonstrate that there were no significant differences between groups for either Time to Aldrete ≥8 (p = .486) or Time to Meet Phase II Criteria (p = .762). Equivalent recovery times for both groups may be an indicator that comparable sedation levels were maintained, despite the increased propofol requirements of the cannabis group. Open conversations to establish patient use of cannabis products prior to procedural sedation is important for determining appropriate plans of care related to risk factors and medication dosage requirements during endoscopic evaluations.
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Affiliation(s)
- Llewellyn Dawn Smith
- Llewellyn Dawn Smith, MSN, RN-BC, CNEcl, is Clinical Nurse IV, Sentara Obici Hospital, Suffolk, Virginia
- Wendy Pelton, MSN, RN, CPAN, is Senior Healthcare Data Analyst, Sentara Enterprise Analytics, Virginia
- Merri K. Morgan, DNP, RN, CCRN, is Magnet Program Manager, Sentara Obici Hospital, Suffolk, Virginia
| | - Wendy Pelton
- Llewellyn Dawn Smith, MSN, RN-BC, CNEcl, is Clinical Nurse IV, Sentara Obici Hospital, Suffolk, Virginia
- Wendy Pelton, MSN, RN, CPAN, is Senior Healthcare Data Analyst, Sentara Enterprise Analytics, Virginia
- Merri K. Morgan, DNP, RN, CCRN, is Magnet Program Manager, Sentara Obici Hospital, Suffolk, Virginia
| | - Merri K Morgan
- Llewellyn Dawn Smith, MSN, RN-BC, CNEcl, is Clinical Nurse IV, Sentara Obici Hospital, Suffolk, Virginia
- Wendy Pelton, MSN, RN, CPAN, is Senior Healthcare Data Analyst, Sentara Enterprise Analytics, Virginia
- Merri K. Morgan, DNP, RN, CCRN, is Magnet Program Manager, Sentara Obici Hospital, Suffolk, Virginia
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Echeverria-Villalobos M, Guevara Y, Mitchell J, Ryskamp D, Conner J, Bush M, Periel L, Uribe A, Weaver TE. Potential perioperative cardiovascular outcomes in cannabis/cannabinoid users. A call for caution. Front Cardiovasc Med 2024; 11:1343549. [PMID: 38978789 PMCID: PMC11228818 DOI: 10.3389/fcvm.2024.1343549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/15/2024] [Indexed: 07/10/2024] Open
Abstract
Background Cannabis is one of the most widely used psychoactive substances. Its components act through several pathways, producing a myriad of side effects, of which cardiovascular events are the most life-threatening. However, only a limited number of studies address cannabis's perioperative impact on patients during noncardiac surgery. Methods Studies were identified by searching the PubMed, Medline, EMBASE, and Google Scholar databases using relevant keyword combinations pertinent to the topic. Results Current evidence shows that cannabis use may cause several cardiovascular events, including abnormalities in cardiac rhythm, myocardial infarction, heart failure, and cerebrovascular events. Additionally, cannabis interacts with anticoagulants and antiplatelet agents, decreasing their efficacy. Finally, the interplay of cannabis with inhalational and intravenous anesthetic agents may lead to adverse perioperative cardiovascular outcomes. Conclusions The use of cannabis can trigger cardiovascular events that may depend on factors such as the duration of consumption, the route of administration of the drug, and the dose consumed, which places these patients at risk of drug-drug interactions with anesthetic agents. However, large prospective randomized clinical trials are needed to further elucidate gaps in the body of knowledge regarding which patient population has a greater risk of perioperative complications after cannabis consumption.
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Affiliation(s)
| | - Yosira Guevara
- Department of Anesthesiology, St Elizabeth’s Medical Center, Brighton, MA, United States
| | - Justin Mitchell
- Department of Anesthesiology & Perioperative Medicine, UCLA Medical Center, Los Angeles, CA, United States
| | - David Ryskamp
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Joshua Conner
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Margo Bush
- University of Toledo, College of Medicine and Life Sciences, Toledo, OH, United States
| | - Luis Periel
- Touro College of Osteopathic Medicine, New York, NW, United States
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Tristan E. Weaver
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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Nachnani R, Knehans A, Neighbors JD, Kocis PT, Lee T, Tegeler K, Trite T, Raup-Konsavage WM, Vrana KE. Systematic review of drug-drug interactions of delta-9-tetrahydrocannabinol, cannabidiol, and Cannabis. Front Pharmacol 2024; 15:1282831. [PMID: 38868665 PMCID: PMC11167383 DOI: 10.3389/fphar.2024.1282831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 03/22/2024] [Indexed: 06/14/2024] Open
Abstract
Background The recent exponential increase in legalized medical and recreational cannabis, development of medical cannabis programs, and production of unregulated over-the-counter products (e.g., cannabidiol (CBD) oil, and delta-8-tetrahydrocannabinol (delta-8-THC)), has the potential to create unintended health consequences. The major cannabinoids (delta-9-tetrahydrocannabinol and cannabidiol) are metabolized by the same cytochrome P450 (CYP) enzymes that metabolize most prescription medications and xenobiotics (CYP3A4, CYP2C9, CYP2C19). As a result, we predict that there will be instances of drug-drug interactions and the potential for adverse outcomes, especially for prescription medications with a narrow therapeutic index. Methods We conducted a systematic review of all years to 2023 to identify real world reports of documented cannabinoid interactions with prescription medications. We limited our search to a set list of medications with predicted narrow therapeutic indices that may produce unintended adverse drug reactions (ADRs). Our team screened 4,600 reports and selected 151 full-text articles to assess for inclusion and exclusion criteria. Results Our investigation revealed 31 reports for which cannabinoids altered pharmacokinetics and/or produced adverse events. These reports involved 16 different Narrow Therapeutic Index (NTI) medications, under six drug classes, 889 individual subjects and 603 cannabis/cannabinoid users. Interactions between cannabis/cannabinoids and warfarin, valproate, tacrolimus, and sirolimus were the most widely reported and may pose the greatest risk to patients. Common ADRs included bleeding risk, altered mental status, difficulty inducing anesthesia, and gastrointestinal distress. Additionally, we identified 18 instances (58%) in which clinicians uncovered an unexpected serum level of the prescribed drug. The quality of pharmacokinetic evidence for each report was assessed using an internally developed ten-point scale. Conclusion Drug-drug interactions with cannabinoids are likely amongst prescription medications that use common CYP450 systems. Our findings highlight the need for healthcare providers and patients/care-givers to openly communicate about cannabis/cannabinoid use to prevent unintended adverse events. To that end, we have developed a free online tool (www.CANN-DIR.psu.edu) to help identify potential cannabinoid drug-drug interactions with prescription medications.
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Affiliation(s)
- Rahul Nachnani
- Department of Pharmacology, Penn State University College of Medicine, Hershey, PA, United States
| | - Amy Knehans
- Department of Library, Penn State University College of Medicine, Hershey, PA, United States
| | - Jeffrey D. Neighbors
- Department of Pharmacology, Penn State University College of Medicine, Hershey, PA, United States
| | - Paul T. Kocis
- Department of Pharmacology, Penn State University College of Medicine, Hershey, PA, United States
- Department of Pharmacy, Penn State University College of Medicine, Hershey, PA, United States
| | - Tzuo Lee
- PA Options for Wellness, Harrisburg, PA, United States
| | - Kayla Tegeler
- PA Options for Wellness, Harrisburg, PA, United States
| | - Thomas Trite
- PA Options for Wellness, Harrisburg, PA, United States
| | - Wesley M. Raup-Konsavage
- Department of Pharmacology, Penn State University College of Medicine, Hershey, PA, United States
| | - Kent E. Vrana
- Department of Pharmacology, Penn State University College of Medicine, Hershey, PA, United States
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Hasckel Gewehr JL, Enzele ML, Freiria LM, Nunes MM, Spengler J, Dondoerfer Teixeira AP, Amazonas E, Sasso Padilha V. Full spectrum cannabidiol-rich extract reduced propofol dosage required for anesthetic induction in dogs-a pilot study. Front Vet Sci 2024; 11:1352314. [PMID: 38645644 PMCID: PMC11026717 DOI: 10.3389/fvets.2024.1352314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/12/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction Cannabinoids show great therapeutic potential, but their effect on anesthesia still remains unclear. Use of chronic recreational Cannabis in humans undergoing anesthetic procedures tends to require a higher dose when compared to non-users. On the other hand, studies on rodents and dogs have shown that cannabinoid agonists may potentiate certain anesthetics. This contrast of effects possibly occurs due to different time lengths of administration of different phytocannabinoids at different doses, and their distinct effects on the Endocannabinoid System, which is also affected by anesthetics such as propofol and isoflurane. Methods Twenty-seven healthy male dogs, client-owned, ranging from 1 to 7 years, and from 5 to 35 kg were selected, mean weight 15.03±7.39 kg, with owners volunteering their animals to participate in the research performed in the Federal University of Santa Catarina (UFSC). Dogs were randomized into 3 groups. The Control Group (CON, n = 9), receiving only Extra Virgin Olive Oil, the same oil-base used in the treatment groups. Group 2 (G2, n = 9) received 2 mg/kg of total phytocannabinoids, and Group 3 (G3, n = 9) received 6 mg/kg of total phytocannabinoids. All groups received their treatments transmucosally, 75 min before their induction with propofol. Heart and respiratory rate, blood pressure, temperature and sedation were evaluated prior to, and at 30, 60, and 75 min after administration of the fsCBD-rich extract or Placebo extract. Preanesthetic medication protocol was also included across all treatment groups, 15 min before induction. Parametric data was analyzed with one-way ANOVA, followed by Student-Newman-Keuls (SNK) if significant statistical differences were found. Non-parametric data was analyzed using Friedman's test, followed by Dunn test for comparisons between all timepoints in the same group. Kruskal-Wallis followed by Dunn was utilized for between groups comparisons. Propofol dose necessary for induction was analyzed through One-way ANOVA followed by Tukey's Multiple Comparisons Test, using Instat by Graphpad, and differences were considered statistically significant when p < 0.05. Our analysis assessed if statistical significance was present between time points in the same group, and between groups in the same time points. Results In our study, 6 mg/kg of total phytocannabinoids were able to reduce the dose of propofol necessary for induction by 23% when compared to the control group. The fsCBD-rich extract did not produce significant sedation within or between groups, although statistically significant differences in heart rate and systolic blood pressure were found. Discussion Our findings indicate that phytocannabinoids could be an adjunct option in anesthesia, although further research is necessary to better confirm this data. Additionally, further research is needed to determine the best dosage, delivery method, time for administration, ideal molecular profile for desired effects, safety, drug-drug interactions, and transurgical effects.
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Affiliation(s)
| | - Maria Laura Enzele
- Veterinary Medicine, Federal University of Santa Catarina (UFSC), Curitibanos, Brazil
| | - Lucas Marlon Freiria
- Veterinary Clinic School (CVE) of the Federal University of Santa Catarina (UFSC), Curitibanos, Brazil
| | - Morgana Martins Nunes
- Veterinary Clinic School (CVE) of the Federal University of Santa Catarina (UFSC), Curitibanos, Brazil
| | - Júlia Spengler
- Veterinary Clinic School (CVE) of the Federal University of Santa Catarina (UFSC), Curitibanos, Brazil
| | | | - Erik Amazonas
- Department of Biosciences and One Health (BSU), Center for Rural Sciences (CCR), Federal University of Santa Catarina (UFSC), Curitibanos, Brazil
- Cannabis Development and Innovation Center (PODICAN/UFSC), Curitibanos, Brazil
| | - Vanessa Sasso Padilha
- Department of Biosciences and One Health (BSU), Center for Rural Sciences (CCR), Federal University of Santa Catarina (UFSC), Curitibanos, Brazil
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Hemmerling TM, Jeffries SD. Robotic Anesthesia: A Vision for 2050. Anesth Analg 2024; 138:239-251. [PMID: 38215704 DOI: 10.1213/ane.0000000000006835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
The last 2 decades have brought important developments in anesthetic technology, including robotic anesthesia. Anesthesiologists titrate the administration of pharmacological agents to the patients' physiology and the needs of surgery, using a variety of sophisticated equipment (we use the term "pilots of the human biosphere"). In anesthesia, increased safety seems coupled with increased technology and innovation. This article gives an overview of the technological developments over the past decades, both in terms of pharmacological and mechanical robots, which have laid the groundwork for robotic anesthesia: target-controlled drug infusion systems, closed-loop administration of anesthesia and sedation, mechanical robots for intubation, and the latest development in the world of communication with the arrival of artificial intelligence (AI)-derived chatbots are presented.
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Affiliation(s)
- Thomas M Hemmerling
- From the Department of Experimental Surgery, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, McGill University, Montreal, Quebec, Canada
| | - Sean D Jeffries
- From the Department of Experimental Surgery, McGill University Health Center, Montreal, Quebec, Canada
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Nasser Y, Biala S, Chau M, Partridge ACR, Yang JY, Lethebe BC, Stinton LM, Cooray M, Cole MJ, Ma C, Chen YI, Andrews CN, Forbes N. Baseline Cannabinoid Use Is Associated with Increased Sedation Requirements for Outpatient Endoscopy. Cannabis Cannabinoid Res 2024; 9:310-319. [PMID: 36269560 DOI: 10.1089/can.2022.0203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Given the underlying properties of cannabinoids, we aimed to assess associations between cannabinoid use and sedation requirements for esophagogastroduodenoscopy (EGD) and colonoscopy. Methods: A prospective cohort study was conducted at three endoscopy units. Adult outpatients undergoing EGD or colonoscopy with endoscopist-directed conscious sedation (EDCS) were given questionnaires on cannabinoid use and relevant parameters. Outcomes included intraprocedural midazolam, fentanyl, and diphenhydramine use, procedural tolerability, and adverse events. Multivariable logistic regression was performed to yield adjusted odds ratios (AORs) of outcomes. Results: A total of 419 patients were included. Baseline cannabinoid use was associated with high midazolam use, defined as ≥5 mg, during EGD (AOR 2.89, 95% confidence interval, CI: 1.19-7.50), but not during colonoscopy (AOR 0.89, 95% CI 0.41-1.91). Baseline cannabinoid use was associated with the administration of any diphenhydramine during EGD (AOR 3.04, 95% CI: 1.29-7.30) with a similar nonsignificant trend for colonoscopy (AOR 2.36, 95% CI: 0.81-7.04). Baseline cannabinoid use was associated with increased odds of requiring high total sedation, defined as any of midazolam ≥5 mg, fentanyl ≥100 mcg, or any diphenhydramine during EGD (AOR 3.72, 95% CI: 1.35-11.68). Cannabinoid use was not independently associated with fentanyl use, intraprocedural awareness, discomfort, or adverse events. Conclusions: Baseline cannabinoid use was associated with higher sedation use during endoscopy with EDCS, particularly with midazolam and diphenhydramine. Given increasingly widespread cannabinoid use, endoscopists should be equipped with optimal sedation strategies for this population. As part of the informed consent process, cannabis users should be counseled that they may require higher sedation doses to achieve the same effect.
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Affiliation(s)
- Yasmin Nasser
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
| | - Soliman Biala
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Millie Chau
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Jeong Yun Yang
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B Cord Lethebe
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Laura M Stinton
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mohan Cooray
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Martin J Cole
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Ma
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Yen-I Chen
- Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Nauzer Forbes
- Department of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
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Ripperger D, Atte A, Ritto F. Cannabis Users Require More Anesthetic Agents for General Anesthesia in Ambulatory Oral and Maxillofacial Surgery Procedures. J Oral Maxillofac Surg 2023; 81:1460-1465. [PMID: 37783364 DOI: 10.1016/j.joms.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/10/2023] [Accepted: 09/10/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND The use of cannabis in the general population has steadily increased over recent years and there is limited literature regarding the anesthetic implications of chronic cannabis use, particularly in the setting of outpatient anesthesia. PURPOSE To determine whether chronic cannabis users undergoing deep sedation or general anesthesia during ambulatory procedures require more anesthetic agents than nonusers. STUDY DESIGN, SETTING, AND SAMPLE A retrospective cohort study of subjects undergoing deep sedation or general anesthesia at the Oklahoma University Oral and Maxillofacial Surgery Clinic from January to December 2022 was performed. The inclusion criteria were duration of anesthetic procedure between 15 to 40 minutes, use of propofol, fentanyl, ketamine, and midazolam, and extraction of at least 2 teeth. The exclusion criterion was patients undergoing adjunctive procedures other than extractions during sedation. PREDICTOR VARIABLE Cannabis use status was grouped as users and nonusers. A user was defined as a subject who self-reported any regular use of cannabis. OUTCOME VARIABLE The primary outcome variable was the amount of intravenous anesthetic agents administered. Secondary outcome variables included the length of the procedure and the number of teeth extracted. COVARIATES Age, sex, and the senior-most resident involved in the sedation. ANALYSES IBM SPSS was utilized to perform descriptive statistics, paired t-tests, ANOVA, and multivariate linear regression. A level of significance of 5% (P < .05) was used for all analyses. RESULTS Four hundred and ninety nine subjects were identified, 189 met the inclusion criteria, and 57 reported using cannabis. The mean age of nonusers was 28.2 ± 7.8 years and that of users was 26.6 ± 6.4 years (P = .09). Females represented 71.9% of nonusers and 72.7% of users. Cannabis users received significantly more propofol (117.5 mg ± 71.3 vs 152.5 mg ± 101.8; P = .004), midazolam (4.7 mg ± 1.0 vs 5.1 mg ± 1.5; P = .01), ketamine (40.2 mg ± 15.7 vs 46.1 mg ± 16.9; P = .01), and fentanyl (75.2 μg ± 26.3 vs 88.6 μg ± 32.8; P = .002) than nonusers, despite extracting a similar number of teeth (4.5 ± 3.1 vs 4.4 ± 3.5; P = .37) in a similar amount of time (25.5 ± 7.3 vs 27.3 ± 7.8; P = .06). CONCLUSION AND RELEVANCE Cannabis users required more propofol, midazolam, ketamine, and fentanyl than non-cannabis users during outpatient oral and maxillofacial surgery procedures.
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Affiliation(s)
- Daniel Ripperger
- Chief Resident, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK
| | - Antonio Atte
- Resident, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK
| | - Fabio Ritto
- Professor & Program Director, Department of Oral and Maxillofacial Surgery, University of Oklahoma, Oklahoma City, OK.
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Dhodapkar MM, Oghenesume OP, Halperin SJ, Modrak M, Yoo BJ, Grauer JN. Adverse Events After Ankle Fracture Open Reduction Internal Fixation Among Patients With and Without Documented Cannabis and Tobacco Use. Foot Ankle Int 2023; 44:941-948. [PMID: 37698277 DOI: 10.1177/10711007231189698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND Ankle fractures are common orthopaedic injuries that may be indicated for open reduction internal fixation (ORIF). Although the negative impact of tobacco use on perioperative outcomes of ankle fracture ORIF has been described, the potential impact of cannabis use on related outcomes is not as well established. METHODS Retrospective database study of adult patients undergoing ankle ORIF for closed, isolated, ankle fractures from the 2010-2021 Q1 PearlDiver M151 data set. Subcohorts without and with cannabis and/or tobacco use were identified based on coding and matched based on patient age, sex, and Elixhauser Comorbidity Index (ECI) scores to yield groups of nonusers, tobacco users, tobacco and cannabis users, and cannabis users. Ninety-day adverse events were assessed between matched subcohorts with multivariable logistic regression controlling for age, sex, and ECI. RESULTS A total of 149 289 patients met study inclusion criteria for whom tobacco only use was documented for 14 989 (10.0%), tobacco and cannabis use for 2726 (1.8%), and cannabis only use for 867 (0.6%). Matching yielded 823 for each group. On multivariable analyses, isolated tobacco users were at higher odds of 90-day urinary tract infections (UTIs) (odds ratio [OR] 2.64), minor adverse events (OR 2.33), all-cause adverse events (OR 2.17), readmissions (OR 1.85), and severe adverse events (OR 1.84). Tobacco and cannabis comorbid users were at a marginally higher odds of 90-day UTI (OR 2.82), minor adverse events (OR 2.51), readmissions (OR 2.39), and any adverse events (OR 2.22). Cannabis only users were not at greater odds of 90-day adverse events relative to nonusers. CONCLUSION Patients with tobacco use (alone or with cannabis) were at greater odds of 90-day adverse events following ankle fracture ORIF, but cannabis only users were not. LEVEL OF EVIDENCE Level III, Retrospective database study.
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Affiliation(s)
- Meera M Dhodapkar
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | | | - Scott J Halperin
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Maxwell Modrak
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Brad J Yoo
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Jonathan N Grauer
- Department of Orthopedics & Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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10
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Saidman J, Rubin S, Swaminath A. Inflammatory bowel disease and cannabis: key counseling strategies. Curr Opin Gastroenterol 2023; 39:301-307. [PMID: 37144523 DOI: 10.1097/mog.0000000000000946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Cannabis use is becoming more frequent in patients with inflammatory bowel disease (IBD). Because of the increased usage, gastroenterologists need to be cognizant of the benefits and risks associated with cannabis use in the IBD-patient population. RECENT FINDINGS Recent studies have attempted to determine whether cannabis can improve biomarkers or endoscopic findings of inflammation in patients with IBD, but the results have been inconclusive. However, cannabis has been shown to have an impact on the symptoms and quality of life of individuals with IBD. Despite these benefits, the use of cannabis in IBD is not without risks, including the potential for systemic illness, toxin ingestion and significant drug interactions. SUMMARY In this review article, we use a case-based approach to discuss the critical clinical data that informs us of the benefits and risks of cannabis use in IBD. The endocannabinoid system plays a crucial role in regulating various physiological functions including the gastrointestinal tract. Studies have investigated the impact of cannabis on various medical conditions, including IBD. Clinicians must be aware of the most recent data to properly educate their patients on the benefits and risks of its use.
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Affiliation(s)
- Jakob Saidman
- Division of Gastroenterology and Hepatobiliary Diseases, Westchester Medical Center, Valhalla
| | | | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, USA
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Gangwani P, Lillian D, Dobbins J, Feng C, Vorrasi J, Kolokythas A. Is Recreational Marijuana Use Associated With Changes in the Vital Signs or Anesthetic Requirements During Intravenous Sedation? J Oral Maxillofac Surg 2023; 81:527-535. [PMID: 36746375 DOI: 10.1016/j.joms.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Pooja Gangwani
- Associate Professor, Department of Oral and Maxillofacial Pathology, Medicine, Surgery, Temple University Kornberg School of Dentistry, Philadelphia, PA.
| | - David Lillian
- Private Practice, Grand Junction Oral Surgery, Colorado
| | - Joshua Dobbins
- Resident, Department of Oral and Maxillofacial Surgery, University of Rochester/EIOH, Rochester, NY
| | - Changyong Feng
- Professor, Department of Biostatistics and Computational Biology, University of Rochester/EIOH, Rochester, NY
| | - John Vorrasi
- Associate Professor, Chair and Program Director, Department of Oral and Maxillofacial Surgery, University of Rochester/EIOH, Rochester, NY
| | - Antonia Kolokythas
- Professor, Chair and Program Director, Department of Oral and Maxillofacial Surgery, The Dental College of Georgia, Professor of Surgery, Augusta, GA
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Walker F, Baric A, Sekharan L, James E, Farook F, Itrat Q, Jagadheesan K. Anaesthetic safety with undisclosed substance misuse during electroconvulsive therapy. Australas Psychiatry 2022; 30:278-279. [PMID: 35073783 DOI: 10.1177/10398562211057076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gallagher JP, Twohig PA, Crnic A, Rochling FA. Illicit Drug Use and Endoscopy: When Do We Say No? Dig Dis Sci 2022; 67:5371-5381. [PMID: 35867192 PMCID: PMC9306238 DOI: 10.1007/s10620-022-07619-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/11/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Illicit drug use (IDU) is often encountered in patients undergoing elective ambulatory surgical procedures such as endoscopy. Given the variety of systemic effects of these drugs, sedation and anesthetics are believed to increase the risk of cardiopulmonary complications during procedures. Procedural cancelations are common, regardless of the drug type, recency of use, and total dosage consumed. There is a lack of institutional and society recommendations regarding the optimal approach to performing outpatient endoscopy on patients with IDU. AIM To review the literature for current recommendations regarding the optimal management of outpatient elective endoscopic procedures in patients with IDU. Secondary aim is to provide guidance for clinicians who encounter IDU in endoscopic practice. METHODS Systematic review of PubMed, CINAHL, Embase, and Google Scholar for articles presenting data on outcomes of elective procedures in patients using illicit drugs. RESULTS There are no clinically relevant differences in periprocedural complications or mortality in cannabis users compared to non-users. Endoscopy in patients with remote cocaine use was also found to have similar outcomes to recent use. CONCLUSIONS Canceling endoscopic procedures in patients with recent IDU without consideration of the type of drug, dosage, and chronicity may lead to unnecessary delays in care and increased patient morbidity. Healthcare systems would benefit from additional guidelines for evaluating the patient with recent illicit drug use for acute intoxication and consider proceeding with procedures in the non-toxic population.
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Affiliation(s)
- John P. Gallagher
- Department of Internal Medicine, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE 68198 USA
| | - Patrick A. Twohig
- Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE 68198 USA
| | - Agnes Crnic
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Room B307, 1053 Carling Ave, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Fedja A. Rochling
- Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE 68198 USA
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Stahl DL, Matthews LJ. Caring for Parturients with Substance Use Disorders. Anesthesiol Clin 2021; 39:761-777. [PMID: 34776108 DOI: 10.1016/j.anclin.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Parturients with substance use disorder require expertise to manage the complexity of intoxication, withdrawal, and chronic use as well as ensure adequate analgesia throughout labor. Opioid use disorder in pregnancy has increased more than 4-fold in the past decade, with a 50-fold geographic variability that now dwarfs other substance use in this population. Understanding not only the medical but also the public health and criminal justice implications of substance use disorder is essential to providing optimal care to this at-risk population.
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Affiliation(s)
- David L Stahl
- Department of Anesthesiology, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Leslie J Matthews
- Department of Anesthesiology, The Ohio State University, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA
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