Perioperative care of cannabis users
The perioperative management of patients using cannabis, either for recreational or medical purposes, remains a challenge for the anesthesiologist due to its multi-organ side effects. However, the interactions between cannabinoids and general anesthetic agents, as well as the impact on intraoperative patient care are not yet fully understood. Discussing cannabis pharmacology and perioperative considerations for naïve and chronic users.
The Endocannabinoid System: The Endocannabinoid System (ECS) is a biological system consisting of specific ligands, G protein-coupled cannabinoid receptors (CB-R), neurotransmitters and enzymes mediating the endocannabinoids synthesis and metabolism . N-arachidonoyl-ethanolamine (AEA; anandamide) and 2-arachidonoylglycerol (2-AG) are endocannabinoids (ECBs) synthetized from phospholipids of the cellular membrane after physiological or pathological stimuli.
Cannabinol (CBN) and ∆8-tetrahydrocannabinol (D8-THC) are the main cannabinoid type 1 (CB1-R) and type 2 (CB2-R) receptor agonists. These molecules are classified as phytocannabinoids because they were first identified in the cannabis plant. The CB1-R and CB2-R are part of the family of rhodopsin-like G protein-coupled (Gi/o-protein) receptors (GPR) that bind to phytocannabinoids, endocannabinoids and synthetic cannabinoids. These ligands are highly lipophilic compounds and their effects are mediated by inhibiting the adenylyl cyclase pathway. Additionally, the GPR55 (also known as CB3-R) has been also identified as a cannabinoid receptor present in the human brain and liver.
The administration of THC produces an increase in heart rate with long-lasting conjunctival congestion followed by euphoria, drowsiness, short-term memory and concentration impairment, and reduced cognitive skills. The synthetic analogues provide higher potency with increased risk for complications. High cannabinoid liposolubility favors rapid accumulation in fatty tissue which prolongs its elimination up to several days after exposure. The multi-systemic effects of cannabinoids and their pharmacological interactions with anesthetic agents may lead to serious consequences. Low doses of cannabinoids have been associated with increased sympathetic response (tachycardia, hypertension and increased contractility) with high levels of norepinephrine detected 30 min after use.
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Anesthesiology Case Reports: Open-Access