Cannabis Use: Change in Screening for Primary Care Preoperative Clearance

      Abstract

      Patients are required to obtain preoperative screening 30 days before elective surgery with an emphasis on testing and screening tools to identify patients at risk for perioperative, intraoperative, and postoperative complications. Surgical complications are being reported in patients who have recently consumed cannabis before surgery. As cannabis use becomes more prevalent for both medicinal and recreational reasons, the lack of evidence-based guidelines for preoperative screening in the primary care setting and surgical setting is problematic. To prevent surgical complications, advanced practice registered nurses must obtain a thorough cannabis history with education on abstaining from use before elective surgery.

      Keywords

      American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hour, including 0.5 hour of pharmacology credit, approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.
      A 58-year-old diabetic patient is scheduled for an outpatient rotator cuff elective surgery repair. The patient arrived at the primary care office for surgical clearance screening. Laboratory values were obtained, including hemoglobin A1c and an electrocardiogram revealing normal sinus rhythm. The patient denied smoking but did not disclose daily use of marijuana (smoking up to 3-4 times a day).
      The surgery was uneventful; the patient was extubated and transferred to the postanesthesia care unit. During the postanesthesia care unit admission, the patient developed stridor, dysphagia, and hypoxia. Intubation was not possible because of acute uvular swelling, and an emergency airway was performed. The patient was transferred to the intensive care unit for treatment of acute uvulitis and additional monitoring. If close monitoring had not been performed, patient fatality could have occurred.
      This case demonstrates the necessity for preoperative guideline changes to ensure providers are screening and educating patients on marijuana consumption before surgery to prevent complications and even death. The patient later admitted the inhalation of marijuana 3 hours before the elective surgery.

      History of Cannabis

      The cannabis plant, commonly known as marijuana, is a mind-altering, psychoactive drug and is 1 of the oldest plants with an extensive history of not only recreational but also medicinal use.
      • Horvath C.
      • Carrie C.
      • Dalley B.
      Marijuana use in the anesthetized patient: history, pharmacology, and anesthetic considerations.
      The medical use of cannabis has garnered much attention in recent years due to increasing legalization across the nation. Consumption is on the rise, with 33 states and Washington DC legalizing cannabis for medical use.
      • Cuomo S.
      • Abate M.
      • Springer C.
      • Kessel D.
      • Bracken D.
      • Fischer-Cartilage E.
      Nurse practitioner-driven optimization of presurgical testing.
      As reported in 2017, cannabis use increased by 43% in people ≥ 26 years old,
      • Twardowski M.A.
      • Link M.M.
      • Twardowski N.M.
      Effects of cannabis use on sedation requirements for endoscopic procedures.
      and according to the World Health Organization, marijuana consumption had a prevalence rate of 147 million individuals.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      The cannabis plant can be traced back millions of years and was indigenous to the Asian continent.
      • Pollio A.
      The name of cannabis: a short guide for nonbotanists.
      Western medicine was introduced to cannabis in the early 1800s by a physician named W.B. O’Shaughnessy.
      • Horvath C.
      • Carrie C.
      • Dalley B.
      Marijuana use in the anesthetized patient: history, pharmacology, and anesthetic considerations.
      He began to create hemp preparations for animals and then later treated patients for inflammation, pain, muscle spasms, anxiety, insomnia, and seizures with the cannabis product.
      • Horvath C.
      • Carrie C.
      • Dalley B.
      Marijuana use in the anesthetized patient: history, pharmacology, and anesthetic considerations.
      The late 19th century saw a decrease in the use of cannabis because of the medical advances of the hypodermic needle and opiates,
      • Horvath C.
      • Carrie C.
      • Dalley B.
      Marijuana use in the anesthetized patient: history, pharmacology, and anesthetic considerations.
      and then during the 20th century, cannabis became primarily a recreational drug.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.
      However, by 1970, all cannabis products were labeled as a Schedule I drug, designating its high potential for abuse.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.

      Cannabis Debate and Medicinal Recommendations

      Controversy and debate still continue regarding cannabis use as a therapeutic agent.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      There are positive effects from cannabis consumption on managing pain, reducing nausea and vomiting, preserving vision, and providing weight gain in patients with human immunodeficiency virus/AIDS.
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.
      These documented medical advancements have changed the perspective regarding cannabis, as well as the collateral effect of the opioid epidemic and public perception.
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.
      Opponents for the legalization of medicinal cannabis assert cannabis intake poses a multitude of health risks, including intoxication and impairing effects, demonstrating that evidence is lacking to confirm the benefits and harm of the drug.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      The medical community has joined the debate vocalizing concerns of limited research in relation to recent cannabis consumption before surgery and outcomes.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      Even with the lack of research, cannabis continues to be regularly taken to alleviate a variety of ailments, such as disorders of chronic pain, the alleviation of nausea and vomiting from chemotherapy, glaucoma, and inflammatory bowel disease.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      Because of the upsurge of unregulated medicinal use of cannabis, advanced practice registered nurses (APRNs) performing preoperative clearances, certified registered nurse anesthetists (CRNAs), and surgeons now state that cannabis is problematic and evidence-based practice is crucial.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      The absence of significant evidence-based literature regarding proper cannabis perioperative screening and education has left providers questioning their efforts while striving for excellence in patient outcomes.

      Biologic Chemistry, Pharmacokinetics, and Pharmacologic Activity

      Cannabinoids are lipophilic and plant derived and mimic endogenous compounds referred to as endocannabinoids.
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      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.
      These endogenous compounds include a wide range of physiological actions via activation or inhibition at the cannabinoid receptor type 1 and 2 (CB1 and CB2, respectively) sites.
      • Fine P.G.
      • Rosenfeld M.J.
      The endocannabinoid system, cannabinoids, and pain.
      Alternatively, cannabinol lacks any psychoactive properties but will exhibit a wide range of pharmacologic activity.
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.
      There are more than 100 biologically active non-tetrahydrocannabinol (THC) cannabinoids, and the cannabis plant contains about 400 compounds from its secondary metabolism, contributing to its medicinal effects.
      • Abrams D.I.
      • Guzman M.
      Cannabis in cancer care.
      These endogenous cannabinoids (Δ9-THC and cannabinol) are plant-based compounds referred to as phytocannabinoids or endocannabinoids, signifying many biologic effects.
      • Abrams D.I.
      • Guzman M.
      Cannabis in cancer care.
      Cannabinoid receptors (CB1) are coupled to G proteins, with a mapped location primarily found in the basal ganglia, cerebellum, hippocampus, and cerebral cortex and prevalent in all body tissues.
      • Abrams D.I.
      • Guzman M.
      Cannabis in cancer care.
      The cannabinoid receptor (CB2), was originally detected in macrophages; however, the highest abundance is located in the B lymphocytes and natural killer cells, which explains their role in immunity.
      • Abrams D.I.
      • Guzman M.
      Cannabis in cancer care.
      In addition to the plant-derived endocannabinoids, there are synthetic laboratory-derived compounds. Some forms of these compounds may be a prescribed pharmacologic medication that the Food and Drug Administration approved or abused agents like K2 or “Spice.”
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      ,
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.
      The complex pharmacokinetics of cannabinoids is difficult to predict because of the variability of Δ9-THC concentrations, the route of administration, metabolism, and elimination.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.
      Cannabinoids are rapidly distributed through vessel-rich groups to CB1 and CB2 and delivered by several routes of administration, such as inhaled, oral, sublingual, dermal, and anal.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.
      The effects of cannabis are dependent on the mode of administration, absorption, frequency of use, chronic or new user, product lipophilicity, and bioavailability, as well as the inherent organ tissue differences (ie, alveolar, gastric, dermal, and rectal).
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.

      Current Methods of Ingestion

      According to the Journal of Forensic Sciences, Δ9-THC potency trends are on the rise.
      • Mehmedic Z.
      • Chandra S.
      • Slade D.
      • et al.
      Potency trends of Δ9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008.
      Confiscated marijuana samples with concentrations of Δ9-THC > 9% increased from 3.23% (1993) to a maximum of 21.47% (2007).
      • Mehmedic Z.
      • Chandra S.
      • Slade D.
      • et al.
      Potency trends of Δ9-THC and other cannabinoids in confiscated cannabis preparations from 1993 to 2008.
      Cannabis dosage and the route of administration, along with last consumption, are imperative to evaluate for possible effects or even cancellation of elective surgery.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      The number of identifiable extractable compounds has increased dramatically from 60
      • Ashton C.H.
      Adverse effects of cannabis and cannabinoids.
      to over 500 in the last 20 years,
      • Beaulieu P.
      • Boulanger A.
      • Desroches J.
      • Clark A.J.
      Medical cannabis: considerations for the anesthesiologist and pain physician.
      of which over 100 are cannabinoids.
      • Bie B.
      • Wu J.
      • Foss J.F.
      • Naguib M.

       Inhaled (Smoked or Vaped)

      Inhalation is the most common way to consume cannabis. Intoxication occurs within 2 minutes after the first inhalation and lasts 2 to 4 hours, and most strains today are stronger, ranging from 15% to 25% of Δ9-THC.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.
      Studies show that inhaled doses of 2 to 3 mg Δ9-THC can cause impairment of executive functioning.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.

       Edible

      Edibles are becoming a popular route of consumption. Dispensaries sell a plethora of food items, including beverages, candies, cookies, honey sticks, cakes, and cooking oils.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.
      ,
      • Barrus D.G.
      • Capogrossi K.L.
      • Cates S.C.
      • et al.
      Tasty THC: promises and challenges of cannabis edibles.
      When edible products are ingested, Δ9-THC is absorbed inconsistently and quickly metabolized by the first-pass effect.
      • Barrus D.G.
      • Capogrossi K.L.
      • Cates S.C.
      • et al.
      Tasty THC: promises and challenges of cannabis edibles.
      This physiological response will lead to a strong association between edible use and overconsumption.
      • Barrus D.G.
      • Capogrossi K.L.
      • Cates S.C.
      • et al.
      Tasty THC: promises and challenges of cannabis edibles.
      Users will feel the impact of Δ9-THC in 2 to 4 hours, and it will last 6 to 8 hours.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.

       Cannabis Oils and Topical Cannabis

      Cannabis oils are crude concentrates and can be taken orally as a liquid or placed in food items.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.
      Most topical cannabis products are available in lotions, creams, and oils that do not absorb well systemically and are used mostly for skin inflammation.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.

       Rectal Suppositories

      Cannabis extracts are dissolved and incorporated into an oil or butter and inserted into the rectum with rapid systemic effects.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.
      This particular route of administration helps to reduce psychoactive symptoms, which is ideal for people who use marijuana for medical and not recreational purposes.
      • Peters J.
      • Chien J.
      Contemporary routes of cannabis consumption: a primer for clinicians.
      Discrepancies in potency, uptake, and drug effects exist between the varied routes of cannabis administration. For example, inhalation of marijuana cigarettes may be apparent within seconds to minutes, whereas oral ingestion may be delayed 2 hours.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.
      In a small trial of 11 healthy subjects, Δ9-THC was administered intravenously, via inhalation, and by mouth.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      Of the 3 methods of administration, plasma levels were parallel when compared between smoking or given intravenously.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      This further demonstrates that the similar effects of cannabis may be produced during inhalation and intravenous administration.
      • Bridgeman M.B.
      • Abazia D.T.
      Medicinal cannabis: history, pharmacology, and implications for the acute care setting.
      The metabolism and breakdown of Δ9-THC primarily occur by the liver, in which metabolites are eliminated via urine, bile, and stool.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.
      Cannabinoids accumulate in the fatty tissue; therefore, Δ9-THC can be detected in urine for more than 30 days. However, 90% of Δ9-THC is eliminated within 5 days.
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.
      ,
      • Kumar R.N.
      • Chambers W.A.
      • Pertwee R.G.
      Pharmacological actions and therapeutic uses of cannabis and cannabinoids.

      Physiological Effects of Cannabis Intraoperatively and Postoperatively

       Pain and Inflammation

      Cannabidiol is an integral component of cannabis with virtually no psychoactivity compared with Δ9-THC but acts as an agonist at CB2.
      • Fine P.G.
      • Rosenfeld M.J.
      The endocannabinoid system, cannabinoids, and pain.
      This reaction at CB2 is accountable for the majority of anti-inflammatory effects, which influences pain responses.
      • Fine P.G.
      • Rosenfeld M.J.
      The endocannabinoid system, cannabinoids, and pain.
      A reduction in pain response is clear; however, it is uncertain how the effect is triggered because pain experiences are altered by a state of perception.
      • Fine P.G.
      • Rosenfeld M.J.
      The endocannabinoid system, cannabinoids, and pain.
      Furthermore, in this population of individuals, recent trials have shown higher pain scores that require greater amounts of analgesics in the intraoperative phase.
      • Alexander J.C.
      • Joshi G.P.
      A review of the anesthetic implications of marijuana use.

       Cognitive Effects

      The effects from higher doses of Δ9-THC act on the central nervous system, which include euphoria, leading to the widespread recreational use for relaxation.
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.
      ,
      • Ashton C.H.
      Adverse effects of cannabis and cannabinoids.
      Central nervous system depressant effects from cannabis that produce drowsiness and sleep are similar to those effects of alcohol and benzodiazepine usage.
      • Ashton C.H.
      Adverse effects of cannabis and cannabinoids.
      More importantly, the Δ9-THC concentration will influence the postoperative effects, which may vary from a “high” to more unwanted experiences, such as stress, panic, paranoia, and anxiety.
      • Teitel A.
      • Bozimowski G.
      A review of pharmacology and anesthetic implications of cannabis.

       Respiratory Effects

      Cannabis smoke contains the same components (apart from nicotine) as tobacco smoke, activating bronchial irritants, tumor promoters, and carcinogens.
      • Ashton C.H.
      Adverse effects of cannabis and cannabinoids.
      Furthermore, chronic cannabis smokers have cause for concern because marijuana inhalation is associated with bronchitis, emphysema, and squamous cell metaplasia (precancerous) of the tracheobronchial epithelium.
      • Ashton C.H.
      Adverse effects of cannabis and cannabinoids.
      Moreover, results found a strong association to concomitant cannabis and tobacco smoking with an increased incidence of spontaneous pneumothorax linked by dose-dependent use in heavy smokers.
      • Olesen W.H.
      • Katballe N.
      • Sindby J.E.
      • et al.
      Cannabis increased the risk of primary spontaneous pneumothorax in tobacco smokers: a case-control study.
      Attention to surgical patients with recent cannabis use before surgery must be considered because they can experience acute uvular edema, airway obstruction, asphyxia, and even brain damage.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.

       Cardiovascular Effects

      Cardiovascular complications resulting from cannabis use are prevalent and common in the perioperative period. Marijuana use may trigger acute or chronic cardiovascular events and can create a series of electrocardiographic changes.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      ,
      • Sidney S.
      Cardiovascular consequences of marijuana use.
      Cannabis use may also trigger premature ventricular contractions, atrial fibrillation, atrioventricular block, or, worst-case scenario, coronary artery plaque rupture and myocardial infarction.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      ,
      • Sidney S.
      Cardiovascular consequences of marijuana use.
      Acute ingested doses of Δ9-THC will increase the heart rate as much as 50% to 60% and are also associated with a modest increase in blood pressure.
      • Sidney S.
      Cardiovascular consequences of marijuana use.
      This response is a result of beta-sympathetic activity and a reduction in parasympathetic activity, which are mediated by CB2 found in the peripheral tissues.
      • Sidney S.
      Cardiovascular consequences of marijuana use.
      Tolerance to cannabinoids will develop with chronic use over a few weeks in which postural hypotension becomes a more prevalent side effect.
      • Sidney S.
      Cardiovascular consequences of marijuana use.

       Coagulation Effects

      Anandamide N-arachidonylethanolamine is part of the endocannabinoid system; it is a short-lived molecule that is present on platelets and influences platelet function and its responsiveness.
      • De Angelis V.
      • Koekman A.C.
      • Weeterings C.
      • et al.
      Endocannabinoids control platelet activation and limit aggregate formation under flow.
      Individuals who consume Δ9-THC and its components (anandamide N-arachidonylethanolamine) are at risk for thromboembolism, stroke, and cardiovascular events, such as myocardial infarction.
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      ,
      • De Angelis V.
      • Koekman A.C.
      • Weeterings C.
      • et al.
      Endocannabinoids control platelet activation and limit aggregate formation under flow.
      Elements of the cannabis product release adenosine diphosphate from erythrocytes, leading to platelet aggregation and a reduction in platelet counts
      • De Angelis V.
      • Koekman A.C.
      • Weeterings C.
      • et al.
      Endocannabinoids control platelet activation and limit aggregate formation under flow.
      ; this is especially concerning for the surgical candidate (Table 1).
      Table 1Anesthetic Considerations in Patients Consuming Cannabis Before Surgery
      PerioperativeElevated risk of myocardial infarction within 1 hour after marijuana use

      Airway hyperactivity

      Anxiety/paranoia

      Psychosis
      IntraoperativeTolerance to induction agents

      Elevated risk of myocardial infarction

      Airway hyperactive

      Uvular edema

      Stroke

      Unknown cross sensitivity to another anesthetic agents
      PostoperativeHeightened pain perception

      Withdrawal

      Poor wound healing

      Preoperative Screening by APRNs in a Primary Care Setting

      APRNs play a pivotal role as members of the preoperative team in the primary care setting, granting surgical clearance. Current Joint Commission guidelines advise surgical candidates to have a preoperative screening within 30 days in advance for elective surgery.
      • Edwards A.
      • Slawski B.
      Preoperative evaluation.
      This guideline emphasizes that particular testing and screening tools are based on need, especially to identify patients at risk for perioperative, intraoperative, and postoperative complications.
      • Cuomo S.
      • Abate M.
      • Springer C.
      • Kessel D.
      • Bracken D.
      • Fischer-Cartilage E.
      Nurse practitioner-driven optimization of presurgical testing.
      To further reduce surgical morbidity and minimize costly surgical delays, presurgical testing is considered vital to patient safety and a component to favorable surgical outcomes.
      • Edwards A.
      • Slawski B.
      Preoperative evaluation.
      The American Society of Anesthesiologists defines routine preoperative tests as assessments completed in the absence of any specific clinical indication which typically include a comprehensive metabolic panel, a complete blood count, urinalysis, a chest x-ray, and an electrocardiogram
      • Richtig G.
      • Bosse G.
      • Arlt F.
      • Heymann C von
      Cannabis consumption before surgery may be associated with increased tolerance of anesthetic drugs: a case report.
      (Table 2). Patients undergoing surgery are not homogenous and have considerable variations in demographic characteristics, along with underlying health and comorbidities.
      Table 2A Primary Care Provider Routine Preoperative Examination Before Surgery
      HistoryDocumentation of past history, a review of current symptoms, a list of allergies, past surgical history, and family history
      Physical examinationWeight, vital signs, and documentation of any abnormal findings on examination (cardiac and respiratory
      Referrals such as cardiology or pulmonology before surgery if needed.
      )
      AssessmentA list of medical problems and a plan for each problem identified
      Preoperative testing abnormalities need to be communicated from advanced practice registered nurses performing surgical clearance to the surgeons and anesthesia providers before elective surgery.
      LabsCBC, CMP, PT, APTT, urinalysis, and A1c
      DiagnosticsECG, echocardiogram, CXR
      Proposed guideline:

      Screening and education of cannabis consumption, dose, route, and frequency

      Discussion of operative risks and complications, with all forms of cannabis consumption. Abstaining 12 to 72 hours, at minimum, before elective surgery should be recommended to prevent serious adverse airway events and increased anesthesia requirements.
      • Horvath C.
      • Carrie C.
      • Dalley B.
      Marijuana use in the anesthetized patient: history, pharmacology, and anesthetic considerations.
      ,
      • Twardowski M.A.
      • Link M.M.
      • Twardowski N.M.
      Effects of cannabis use on sedation requirements for endoscopic procedures.
      ,
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      ,
      APTT = activated partial thromboplastin time; CBC, complete blood count; CMP, comprehensive metabolic panel; CXR, chest x-ray; ECG, electrocardiogram; PT, prothrombin time.
      a Referrals such as cardiology or pulmonology before surgery if needed.
      b Preoperative testing abnormalities need to be communicated from advanced practice registered nurses performing surgical clearance to the surgeons and anesthesia providers before elective surgery.
      Costly intraoperative and postsurgical complications from cannabis use can occur, which is substantial to the patient and the hospital.
      • Richtig G.
      • Bosse G.
      • Arlt F.
      • Heymann C von
      Cannabis consumption before surgery may be associated with increased tolerance of anesthetic drugs: a case report.
      Thus, primary care presurgical screening aims to bring awareness to providers of any medical concerns, along with possible delays for their elective surgery, based on the patient’s history or findings. What are we missing? An essential question of frequency, route of administration, and education regarding cannabis consumption during the patient’s primary care surgical screening and clearance to prevent operative complications. The earlier the patient refrains from all types of marijuana products before surgery, their overall risk of complications decreases. Connecting with the surgical team and anesthesia provider before surgery regarding frequency, dosage, and ingestion will increase safety and patient outcomes.
      A short-term time frame from marijuana abstinence is 12 to 72 hours,,
      • Echeverria-Villalobos M.
      • Todeschini A.B.
      • Stoicea N.
      • Fiorda-Diaz J.
      • Weaver T.
      • Bergese S.D.
      Perioperative care of cannabis users: a comprehensive review of pharmacological and anesthetic considerations.
      and up to 8 weeks before surgery is optimal. Recommendations on cannabis abstinence before surgery varies by authors; however, all forms of cannabis consumption 12 to 72 hours (at a minimum) before elective surgery is the common recommendation in the literature to prevent serious adverse airway events and increased anesthesia requirements.

      Preassessment Evaluation by Nurse Anesthetists

      Marijuana use is typically self-reported by 14% of surgical patients,
      • Huson H.B.
      • Granados T.M.
      • Rasko Y.
      • Huson H.B.
      Surgical considerations of marijuana use in elective procedures.
      which is similar to other social habits, such as alcohol, cigarette and drug intake is classically underreported. By identifying this trend, a change in assessment practice will help to capture a portion of patients who may be consuming cannabis products on a regular basis. There is a heightened concern regarding the synergistic effects of cannabis that include: potentiation of nondepolarizing muscle relaxants, potentiation of norepinephrine, and the augmentation of any drug that may cause respiratory or cardiac depression.,
      • Dickerson S.J.
      Cannabis and its effect on anesthesia.
      The assessment of cannabis use pertaining to the surgical patient is briefly considered or questioned during presurgery clearance by the APRN/CRNA. A routine formal cannabis-centered assessment should be incorporated into preassessment practices, initiating a conversation between the patient and the APRN/CRNA. Assessing for chronic or new cannabis use, frequency, route of administration, and last documented intake are all vital to the anesthesia plan of care and patient outcome. This especially holds true if such data are not retrieved or reported by the primary care APRN during the preoperative screening and clearance assessment.
      A typical preanesthesia cannabis assessment would include the route of administration, chronic or naive user, timing, and last intake. As practitioners, we understand that this information is sensitive and considered confidential, which is vital to developing a trusting patient relationship. However, patients continue to be reluctant and untruthful pertaining to their usage habits. These authors recommend that, in addition to investigating usage during each assessment, the practitioner should explain that this information is confidential and a priority to delivering a safe anesthetic. Recommendations from Harvard Health Publishing state the following: “please do not be afraid to disclose your use of marijuana, as it will not affect what we think of you.”
      • Hepner D.
      Coming clean: your anesthesiologist needs to know about marijuana use before surgery.

      Conclusion

      A frank conversation with patients regarding potential surgical risks linked to recent cannabis ingestion of all forms must be considered. Further discussion should include how the effects of cannabis can alter anesthesia administration and increase the chance of postoperative complications. These deliberations must be initiated during the primary care initial screening for the surgical clearance appointment, along with abstaining from all forms of cannabis at a minimum of 12 to 72 hours. Communication between APRN primary care providers and the surgical team is paramount to the patient’s well-being, safety, and continuity of care.

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      Biography

      Tammy Sadighi, DNP, FNP, MBA, CHSE, is an assistant professor at Florida Gulf Coast University in Fort Myers, FL and can be contacted at [email protected] .
      Virginia Londahl-Ramsey, DNAP, CRNA, CHSE, is an assistant professor at Florida Gulf Coast University in Fort Myers, FL