Marijuana Associated with Needing More Anesthesia

[Lawpy]

Curious what you guys think:

What Doctors Are Learning About Marijuana and Surgery

People who use cannabis may need more anesthesia during procedures, but many remain wary of mentioning their habit.

www.wsj.com

A recent 2023 review:

Contemplating cannabis? The complex relationship between cannabinoids and hepatic metabolism resulting in the potential for drug-drug interactions - PubMed

The majority of states have fully legalized the use of medical cannabis (MC), and nearly all other states allow limited access to cannabidiol (CBD), a non-intoxicating constituent of cannabis often touted for a range of therapeutic indications. Further, the Agricultural Improvement Act of 2018...

pubmed.ncbi.nlm.nih.gov

2023 ASRA guidelines:

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids | Regional Anesthesia & Pain Medicine

2021 study linking cannabis to greater propofol dosage needed for endoscopy:

High quantities: Evaluating the association between cannabis use and propofol anesthesia during endoscopy - PubMed

Our data suggest that cannabis use is significantly associated with the quantity of propofol needed for sedation at endoscopy. Further study is needed to better understand the molecular basis for this possible drug-drug interaction.

pubmed.ncbi.nlm.nih.gov

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[coffeebythelake]

Curious what you guys think:

What Doctors Are Learning About Marijuana and Surgery

People who use cannabis may need more anesthesia during procedures, but many remain wary of mentioning their habit.

www.wsj.com

A recent 2023 review:

Contemplating cannabis? The complex relationship between cannabinoids and hepatic metabolism resulting in the potential for drug-drug interactions - PubMed

The majority of states have fully legalized the use of medical cannabis (MC), and nearly all other states allow limited access to cannabidiol (CBD), a non-intoxicating constituent of cannabis often touted for a range of therapeutic indications. Further, the Agricultural Improvement Act of 2018...

pubmed.ncbi.nlm.nih.gov

2023 ASRA guidelines:

ASRA Pain Medicine consensus guidelines on the management of the perioperative patient on cannabis and cannabinoids | Regional Anesthesia & Pain Medicine

2021 study linking cannabis to greater propofol dosage needed for endoscopy:

High quantities: Evaluating the association between cannabis use and propofol anesthesia during endoscopy - PubMed

Our data suggest that cannabis use is significantly associated with the quantity of propofol needed for sedation at endoscopy. Further study is needed to better understand the molecular basis for this possible drug-drug interaction.

pubmed.ncbi.nlm.nih.gov

No big surprise. We've seen this anecdotally for a long time. Propofol most strikingly (sometimes 3 or 4 times the usual dose) but also with other anesthetic drugs.

 

[Iso4ane]

Anesthesia is like cracking nuts open with a stone. If one hit doesn't do the job it takes another hit (or two sometimes). And vice versa if the shell is too soft, too hard of a whack and you get yourself into some trouble.

 

[UscGhost]

Not surprised. Consistent with what we see clinically, although not always the case

 

[nimbus]

I haven’t seen a lot of this personally. I don’t work at an endoscopy center. What I CAN say is that the propofol always works if you mix it with roc.

 

[gtb]

PDF of the WSJ article

 

[coffeebythelake]

I haven’t seen a lot of this personally. I don’t work at an endoscopy center. What I CAN say is that the propofol always works if you mix it with roc.

Running TIVAs on heavy marijuana users is always a bit worrisome for me, especially in the absence of brainwave monitoring

 

[jwk]

A couple of my anesthetist friends moved to Colorado, and immediately noticed the increased propofol requirements compared to what they used in Atlanta.

 

[jjm285]

I had a young, healthy, heavy marijuana user for colonoscopy the other day. 60 kg, took 250 to stop talking and ran her at 650 so she would hold still. That was a new record for me.

 

[2Fast2Des]

I have given 9 vials of 20cc prop for a 25 minutes urology case on a skinny 20 something year old, and the guy still woke up in less than 5 minutes looking like nothing happened. And maintaining spontaneous ventilation even when I was giving 100 mg boluses because he kept moving! I wasn't sure if that prop batch was bad since I had people emerging a bit too quickly through the day or he seriously underreported his MJ use, but it may have been a combination. MJ use is no joke, and makes you wonder about recall rate for TIVA cases

 

[Coffee PRN]

I always use a BIS if paralyzing on TIVA

 

[zizzer]

Cannabis is part of my interview with the patient, always following up affirmative answers with, "Do you use it daily, weekly, or monthly?" It's really mostly the daily users that give me the most trouble, sometimes weekly users. For me, I've never found it to be an awareness problem as much as a matter of immobility in the absence of neuromuscular blockade, more so in regard to propofol than volatile anesthetic. Induction seems to be characterized by these strange myoclonic jerks and dystonic movements. Emergence isn't usually as smooth either.

 

[2Fast2Des]

What do you guys recommend to people to stop before operation? I think I've read at least 72 hrs or so? I'm not sure if there is an official consensus. With this growing trend, would be good for the ASA to put something out there

 

[zizzer]

What do you guys recommend to people to stop before operation? I think I've read at least 72 hrs or so? I'm not sure if there is an official consensus. With this growing trend, would be good for the ASA to put something out there

I don't get a chance to and have had people show up who used cannabis before showing up for surgery. I agree it would be nice to have some guidelines.

 

[2Fast2Des]

I don't get a chance to and have had people show up who used cannabis before showing up for surgery. I agree it would be nice to have some guidelines.

For PAT or pre-op evaluation would be helpful so that way they can stop at an appropriate time before

 

[Urzuz]

I had a young, healthy, heavy marijuana user for colonoscopy the other day. 60 kg, took 250 to stop talking and ran her at 650 so she would hold still. That was a new record for me.

650 mcg/kg/min..???

 

[jjm285]

650 mcg/kg/min..???

Yep. Woke up on a dime too. It was pretty impressive.

 

[nimbus]

Yep. Woke up on a dime too. It was pretty impressive.

Damn…that’s 5ml (50mg)/min for average sized patient.

 

[coffeebythelake]

I had a young, healthy, heavy marijuana user for colonoscopy the other day. 60 kg, took 250 to stop talking and ran her at 650 so she would hold still. That was a new record for me.

Prop 650 mcg/kg/min...??! Wonder if a little fentanyl would have smoothed it out better than just upping the propofol

 

[abolt18]

650 mcg/kg/min..???

I've run these rates for peds sedation cases.

 

[nimbus]

I've run these rates for peds sedation cases.

Anti-aging effect of the miracle herb.

 

[Arch Guillotti]

I've run these rates for peds sedation cases.

Damn. Highest I ever went as a resident was 400.

 

[deleted875186]

Cannabis is part of my interview with the patient, always following up affirmative answers with, "Do you use it daily, weekly, or monthly?" It's really mostly the daily users that give me the most trouble, sometimes weekly users. For me, I've never found it to be an awareness problem as much as a matter of immobility in the absence of neuromuscular blockade, more so in regard to propofol than volatile anesthetic. Induction seems to be characterized by these strange myoclonic jerks and dystonic movements. Emergence isn't usually as smooth either.

This is what I see as well. Volatile more reliable, the chronic marijuana uses go through prop like it’s nothing.

 

[abolt18]

Damn. Highest I ever went as a resident was 400.

Crazy thing is they'd still be breathing right through it, and even squirming during the procedure. And this is after letting them settle into it nicely, with a bolus or two to front. Seemed mostly to be the frequent fliers like kids getting their nth LP with intrathecal methotrexate for their cancer. They seem to build a tolerance to the Michael Jackson drug.

 

[Precedex]

Prop 650 mcg/kg/min...??! Wonder if a little fentanyl would have smoothed it out better than just upping the propofol

I like blow-by sevo for this situation.

 

[DocVapor]

I like blow-by sevo for this situation.

Wut

 

[nimbus]

I like blow-by sevo for this situation.

Wut

Yes, please. Tell us more.

 

[abolt18]

I like blow-by sevo for this situation.

I don't know what this means, but also, we didn't have am anesthesia machine in our peds sedation suites. Just an anesthesia cart, a monitor, and an ambu available. IV meds or bust.