Cocaine

[Noyac]

You are interviewing an ambulatory pt for a hernia repair and the nurse comes up to you to tell you that the pts urine tox screen came up positive for cocaine. The pt is very apprehensive and wants to go to sleep. What do you do? Reschedule the case? Do the case under GA, spinal or local? Surgeon is not very good with local and ends up giving larger doses usually.

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[IN2B8R]

You are interviewing an ambulatory pt for a hernia repair and the nurse comes up to you to tell you that the pts urine tox screen came up positive for cocaine. The pt is very apprehensive and wants to go to sleep. What do you do? Reschedule the case? Do the case under GA, spinal or local? Surgeon is not very good with local and ends up giving larger doses usually.

Detox the patient. It's an elective hernia repair, no? Btw, why was tox screen ordered in the first place, someone was suspicious of this patient?

 

[Noyac]

Detox the patient. It's an elective hernia repair, no? Btw, why was tox screen ordered in the first place, someone was suspicious of this patient?

Surgeon ordered it, let's say. This is a hypothetical case.
Yes, elective case.

 

[Noyac]

Detox the patient. It's an elective hernia repair, no? Btw, why was tox screen ordered in the first place, someone was suspicious of this patient?

Why?

 

[ProRealDoc]

You are interviewing an ambulatory pt for a hernia repair and the nurse comes up to you to tell you that the pts urine tox screen came up positive for cocaine. The pt is very apprehensive and wants to go to sleep. What do you do? Reschedule the case? Do the case under GA, spinal or local? Surgeon is not very good with local and ends up giving larger doses usually.

The fact this pt tested positive indicates recent use as in < 7 days. I'd notify the surgeon of this new finding and in a nonjudgemental manner discuss with the pt the results. If nothing concerning comes up in reviewing their medical hx, I would then proceed to explain the implications cocaine abuse has on anesthetic management and the potential need for further interventions including placement of invasive monitoring, hemodynamic control with pharmacological means, etc.

Because of the potential for hemodynamic derangements intraop and pt's desire to go to sleep, I would go with GA and add opioids generously.

 

[Noyac]

The fact this pt tested positive indicates recent use as in < 7 days. I'd notify the surgeon of this new finding and in a nonjudgemental manner discuss with the pt the results. If nothing concerning comes up in reviewing their medical hx, I would then proceed to explain the implications cocaine abuse has on anesthetic management and the potential need for further interventions including placement of invasive monitoring, hemodynamic control with pharmacological means, etc.

Because of the potential for hemodynamic derangements intraop and pt's desire to go to sleep, I would go with GA and add opioids generously.

Very good ProReal but I have questions.

THis is at an ASC. You don't have invasive monitoring capabilities.

What implications does cocaine use have on anesthetic management?

Why give opioids generously?

 

[sevoflurane]

Agree with above. Do the case if no use in the last 48 hours. GA. Stay away from beta-blockers (just in case he's lying). I'd also be a bit generous on benzodiazepines keeping in mind he may be catecholamine depleted if chronically using.

Had a patient admit to one of my collegues that they had used heroin the morning of surgery because they were nervous.

Case got cancelled if I remember correctly.

 

[ProRealDoc]

Very good ProReal but I have questions.

THis is at an ASC. You don't have invasive monitoring capabilities.

What implications does cocaine use have on anesthetic management?

Why give opioids generously?

By virtue of blocking the reuptake of NE, dopamine and serotonin, the sympathetic response to airway management and surgical stress may be exaggerated and can be life-threatening (i.e, intracranial bleed, LV failure, increased bleeding, etc). My induction goals would include use agents that would minimize any wide fluctuations of hemodynamics up to and including alpha/beta blockers and opioids.

Granted opiods are not a substitute for cocaine, but having an already-apprehensive pt arrive in the PACU in pain can exacerbate withdrawal symptoms and will preclude quick recovery and discharge. This is why I would use opioids liberally.

 

[sevoflurane]

Very good ProReal but I have questions.

THis is at an ASC. You don't have invasive monitoring capabilities.

What implications does cocaine use have on anesthetic management?

Why give opioids generously?

Acutely you would have an increase in MAC requirements. Chronic you may or may not have a decrease in MAC requirements. Tailer your anesthetic for smooth trasitions during intubation and extubations (deep extubation). Keep their HR at about... 48bpm😀

Beta-blockers: During acute ingestion you would get unopossed alpha constriction and potential for acute coronary vasospasm.

 

[IN2B8R]

Why?

Well, 'cause Cocaine is bad for ya, son: from coronary vasospasm to inhibition of re-uptake of catechols that can lead to hypertensive crises (stimulates central sympatheic outflow), to blah, blah, etc.... These two are bad enough to avoid dealing with patients who are acutely intoxicated on cocaine. But why are you asking us, did your surgeon object to the cancellation?

 

[Surfer]

I'd cancel the case after carefully explaining to the surgeon and the patient why it is an unnecessary risk to do an elective case on somebody with a positive UTOX for cocaine. Its not a risk i'm willing to assume, given the benefit.

 

[IN2B8R]

Very good ProReal but I have questions.

THis is at an ASC. You don't have invasive monitoring capabilities.

What implications does cocaine use have on anesthetic management?

Why give opioids generously?

Oh hell, tell your surgeon that the hernia may turn out fine, but that you have major concerns about the placental abruption in your male patient..

 

[Noyac]

Remember, I said this was a hypothetical case. We only have model citizens where I work.😉

If you were to get this coronary vasospasms IN2B8R, what then would you see? How likely is he to have vasospasms?

Surfer, if you cancel the case what have you solved?

 

[Surfer]

Surfer, if you cancel the case what have you solved?

Well one thing I didn't solve was this guy's hernia. But he's got bigger problems than a hernia if he can't show up on the day of surgery without cocaine in his system. Its all risk/benefit. I'm not comfortable with the risk/benefit ratio in this patient. Sure, i could probably do the case just fine wtihout any complications. But a massive heart attack during a hernia surgery is not what i was hoping for on a friday afternoon.

it has been my experience that very few surgeons even want to take on this type of liability. usually when i see a positive utox, the surgeon has already canceled the case before i see the patient. there is a reason they get the utox--they have suspicions and told the patient "if you use drugs we won't do your surgery." cocaine also has implications in wound healing. its not a surgical condition most surgeons want to deal with, and i don't want to either. that is why i would cancel.

 

[Noyac]

Well one thing I didn't solve was this guy's hernia. But he's got bigger problems than a hernia if he can't show up on the day of surgery without cocaine in his system. Its all risk/benefit. I'm not comfortable with the risk/benefit ratio in this patient. Sure, i could probably do the case just fine wtihout any complications. But a massive heart attack during a hernia surgery is not what i was hoping for on a friday afternoon.

it has been my experience that very few surgeons even want to take on this type of liability. usually when i see a positive utox, the surgeon has already canceled the case before i see the patient. there is a reason they get the utox--they have suspicions and told the patient "if you use drugs we won't do your surgery." cocaine also has implications in wound healing. its not a surgical condition most surgeons want to deal with, and i don't want to either. that is why i would cancel.

How many pts with recent past cocaine use have massive MI's during surgery?

I was unaware of the implications in wound healing. Is this a fact or is it academic dogma?

 

[Surfer]

How many pts with recent past cocaine use have massive MI's during surgery?

I was unaware of the implications in wound healing. Is this a fact or is it academic dogma?

honestly i don't know. like i said, most surgeons don't want anywhere near this patient. i don't see what the point of doing the case is today? its a hernia, tell him to lay off the white stuff and come back next month. honestly i don't think doing the surgery is a big deal even if he used cocaine this morning, but we have a positive utox now, and it was checked for a reason, and if something goes bad i'd have a hard time justifying a hernia surgery in those circumstances.

what do you think? are you wanting to do it or just playing devil's advocate?

 

[Mista Suprane]

hypothetical dude probably had a night on the town last weekend with his boys in NYC, somebody got an eight-ball, he blew a few rails, and now it's wednesday afternoon and he's got some coke in his pee.

if the above fits the description, then i think you all are overreacting. as urge would say... pent, sux, tube.

however, if he looks like tyrone biggums, then yes, you can get all academic with your increased MAC requirements, coronary vasospasm, blah, blah, blah; and maybe make a case for delaying the procedure.

i know everyone here went to medical school, but sometimes in these discussions i have a hard time believing anyone went to college. 🙄

 

[Planktonmd]

Give Propofol, place LMA, do GA.

 

[IN2B8R]

hypothetical dude probably had a night on the town last weekend with his boys in NYC, somebody got an eight-ball, he blew a few rails, and now it's wednesday afternoon and he's got some coke in his pee.

if the above fits the description, then i think you all are overreacting. as urge would say... pent, sux, tube.

however, if he looks like tyrone biggums, then yes, you can get all academic with your increased MAC requirements, coronary vasospasm, blah, blah, blah; and maybe make a case for delaying the procedure.

i know everyone here went to medical school, but sometimes in these discussions i have a hard time believing anyone went to college. 🙄

Hahahahahahaha ROFL

 

[IN2B8R]

Remember, I said this was a hypothetical case. We only have model citizens where I work.😉

If you were to get this coronary vasospasms IN2B8R, what then would you see? How likely is he to have vasospasms?

Surfer, if you cancel the case what have you solved?

So here's an article from the arse-holes of internal medicine, errr Annals of internal Medicine: http://www.annals.org/content/115/1...064510c88bf54f335778a424&keytype2=tf_ipsecsha

Data Synthesis: A total of 114 cases of cocaine-induced myocardial infarction were identified. The coronary anatomy was defined by angiography or autopsy in 92 patients, 38% of whom had normal coronary arteries. In these 35 patients (average age, 32; range, 21 to 60 years), myocardial infarction typically involved the anterior left ventricular wall (77%). Moderate cigarette smoking with one or fewer associated coronary risk factors was prevalent (68%). Focal coronary vasospasm was shown convincingly in only two cases. Intracoronary thrombus was initially found on 9 of 11 angiograms (82%) done within 12 hours of the myocardial infarction. Experimental evidence suggests that cocaine has direct and indirect sympathomimetic effects on vascular smooth muscle, attenuates endothelium vasodilator capacity, exerts a potent depressant effect on cardiac myocytes, and promotes atherogenesis.

&#9642; Conclusions: Cocaine-induced myocardial infarction in patients with normal coronary arteries probably involves adrenergically mediated increases in myocardial oxygen consumption, vasoconstriction of large epicardial arteries or small coronary resistance vessels, and coronary thrombosis. Accelerated atherosclerosis and impairment of endothelium vasodilator function may occur after chronic cocaine use.

Now in relation to your question of what might I "see," my answer would depend on if the patient was anesthetized or not: if patient was awake, he may report symptoms of MI (CP with attendant radiation symptoms, SOB, etc....). If Patient is asleep--at the reported Surgery Center for Model Citizens--then you may see ST changes with attendant hemodynamic changes: possible increased HR, hypotension, dysrhythmias, perhaps even eventual florid heart failure and pulm edema with it's attendant changes in PaO2.... I guess what I am trying to say is: what you would "see" depends on the extent of length of the vasospasm, how the supplied myocardium is affected by the vasospasm, how much "cardiac reserve" did one have to begin with, what prior co-morbidities existed in addition to the simple hernia, etc... You are asking a generalized question to a "standard" patient, problem is, there's not a single answer here: it all depends on the extent of the underlying patient, as all patients are not standard. Also depends on the extent and severity of the vasospasm on the underlying (dependent) myocardium and the relative rebound that the myocardium may/may not have.

Now damn it, that was a lot of typing. Please say that I passed!🙂

 

[nap$ter]

By virtue of blocking the reuptake of NE, dopamine and serotonin, the sympathetic response to airway management and surgical stress may be exaggerated and can be life-threatening (i.e, intracranial bleed, LV failure, increased bleeding, etc). My induction goals would include use agents that would minimize any wide fluctuations of hemodynamics up to and including alpha/beta blockers and opioids.

Granted opiods are not a substitute for cocaine, but having an already-apprehensive pt arrive in the PACU in pain can exacerbate withdrawal symptoms and will preclude quick recovery and discharge. This is why I would use opioids liberally.

1. if the surgeon wants to cancel based on the positive tox screen - end of story. hopefully he told the patient he was getting a tox screen and why, and clearly discussed the consequences. but, i would bet this didn't happen...

2. if the surgeon wants to do the case, you need to figure out whether the patient is ACUTELY intoxicated, or on the down slope of a bender. the anesthetic management is markedly different.

3. if the patient is ACUTELY intoxicated or you don't feel that you can get a straight answer, don't do the case. the risk of hyper/hypo tensive cardiac events is not worth it for an elective case in a day surgery center. explain the risks to the patient and surgeon, and why you are cancelling.

4. if the patient is on the downslope of use ie last night or day before, do the case. seems one third of our patients at the county hospital fall into this boat, whether a tox screen has been done or not. like plank sez, LMA, small dose of propofol, gotime. you just need to be cognizant of the catecholamine-depleted state this patient is in. the BP will drop after induction, and ephedrine ain't gonna work too good. use direct-acting agents. explain the issues/risks to the patient and surgeon, and go for it. don't use opioids liberally, these patients hardly breathe or wake up after a GA - the 2 catechols they have bouncing around don't do much after a little propofol - they're sensitive, not tolerant.

bottom line - the guy needs his hernia fixed, and he probably isn't ever gonna get completely clean based on coke addiction stats. so just get him done when the time is ripe.

we had a similar situation at our county hospital where a young guy c COPD needed lung reduction for a big ole bleb. the surgeon ordered a tox screen suspecting coke, but didn't tell the patient about it and didn't check the results or tell the anesthesia team until we were wheeling the patient back. long story short, we did as described above - did the case after a risk discussion with the patient, clearly documented. pt's BP crashed after induction but responded to moderate phenylephrine bolusses. the procedure was VATS, so no epidural, and the guy hardly needed any opiates but took forever to wake up.

 

[jennyboo]

1) Make sure surgeon is aware & see if s/he wants to proceed with the case. If patient appears acutely intoxicated, I would cancel the case if the surgeon does not -- and I'm guessing surgeon probably would.

2) Document the patient understands risks of general anesthesia in setting of cocaine use.

3) Proceed with case. If he wants a GA, I'd give him a GA. Keep him normotensive and keep his heart rate normal.

4) Nitroglycerin infusion and tell the surgeon to hurry up and finish if he gets ST changes.

 

[jennyboo]

Oh yeah. If he does get ST elevations, kid may end up getting a boatload of aspirin, Plavix, heparin, etc maybe leading up to a cardiac cath. No spinal.

 

[dhb]

Seeing how common cocaine use is and how such few patients confess to cocaine consumption it's my bet that we regularly put people to sleep which would turn out positive if tested...
pent sux ... LMA

 

[gaspasser2004]

From a true risk/benefit perpsective, an elective hernia at an ASC can wait until the patient has cleared the cocaine. As mentioned by other posters, the patient is at increased risk for intraoperative cardiac events and this surgery is not urgent. A bad outcome in this patient, especially cardiac, in the face of a positive urine tox screen, is indefensible. In my opinion, taking this patient to the OR would be below the standard of care.

What you don't learn in residency is that in the real world this case would go to the OR the majority of the time. Unfortunately, production pressure from both the anesthesia and surgical side (but especially the surgical side) push a lot of cases to the OR that probably shouldn't go, especially in physician-owned ASC's.

If you think about it, the practice of anesthesia is one giant casino. We make bets every day with patient care, bets usually stacked way in our favor. We tend to not make stupid bets like putting an LMA in a 300 pounder who just ate McDonald's on the way to their elective knee scope.

Putting a patient to sleep who still has cocaine in their system is a bet that you will win the vast majority of the time. The problem with this particular bet is that if you are unlucky enough to lose (e.g. bad cardiac outcome), the cost is significant (lawsuits, peer review, action on license).

 

[Surfer]

From a true risk/benefit perpsective, an elective hernia at an ASC can wait until the patient has cleared the cocaine. As mentioned by other posters, the patient is at increased risk for intraoperative cardiac events and this surgery is not urgent. A bad outcome in this patient, especially cardiac, in the face of a positive urine tox screen, is indefensible. In my opinion, taking this patient to the OR would be below the standard of care.

What you don't learn in residency is that in the real world this case would go to the OR the majority of the time. Unfortunately, production pressure from both the anesthesia and surgical side (but especially the surgical side) push a lot of cases to the OR that probably shouldn't go, especially in physician-owned ASC's.

If you think about it, the practice of anesthesia is one giant casino. We make bets every day with patient care, bets usually stacked way in our favor. We tend to not make stupid bets like putting an LMA in a 300 pounder who just ate McDonald's on the way to their elective knee scope.

Putting a patient to sleep who still has cocaine in their system is a bet that you will win the vast majority of the time. The problem with this particular bet is that if you are unlucky enough to lose (e.g. bad cardiac outcome), the cost is significant (lawsuits, peer review, action on license).

Exactly! Well said. In the face of a positive UTOX, which we already have, your action will be indefensible should there be a bad outcome. It's simply not worth the risk for a stupid hernia. No, he does not need his hernia fixed right now, its nothing like a lung surgery. its a hernia, and i'm also betting he's not paying for it either. so no, i will not put my license, my retirement, and my career on the line for a hernia surgery with a positive UTOX screen for cocaine. a lawyer would eat any of you alive if there was a bad outcome and there is a real chance there might be. so why risk it?

the truth is, no surgeon will do that case in the face of a positive utox. at least no surgeons i've worked with. to the OP, why did they do the test? they did it for a reason, ie, they wanted to know if he was on cocaine so they could cancel if he was.

 

[SleepIsGood]

I'd cancel the case after carefully explaining to the surgeon and the patient why it is an unnecessary risk to do an elective case on somebody with a positive UTOX for cocaine. Its not a risk i'm willing to assume, given the benefit.

At a ASC...all bets are off. I agree with Surfer here.

I think you need an EKG (mk sure this guy hasnt already infarcted previously or has some arrythmias from the coccaine use).

This is an elective case. If it were emergent...totally different..and you would need an A line. IF you are at an ASC that doesnt have invasive monitoring capabilities, then you surely shouldnt be doing this case.

What have I achieved from not doing this case and rescheduling it? Perhaps a decrease in morbidity and mortality. This patient is at high risk from a CVS point of view. He needs to be off these street drugs and if his BP is high, it needs to be controlled. Further, if he stated he quit 3 days ago...I would still assume he's lying a little bit.

Reschedule when utox is negative. Tell him that otherwise he can die.

 

[Intubate]

Agree with above. Do the case if no use in the last 48 hours. GA. Stay away from beta-blockers (just in case he's lying). I'd also be a bit generous on benzodiazepines keeping in mind he may be catecholamine depleted if chronically using.

Had a patient admit to one of my collegues that they had used heroin the morning of surgery because they were nervous.

Case got cancelled if I remember correctly.

Of course. You can't safely anesthetize someone with opioids in their system.

 

[Intubate]

Should you cancel a patient who takes their adderall or dexedrine? I think you all would have to say yes by your line of reasoning.

 

[GasEmDee]

bottom line - the guy needs his hernia fixed, and he probably isn't ever gonna get completely clean based on coke addiction stats. so just get him done when the time is ripe.

I generally agree with the rest, but not this. It's a hernia. He'll live with it. Not worth risking your license with a complication. This isn't cutting out a cancer or evacuating a symptomatic subdural. Just wait till he is past the acute phase.

 

[sevoflurane]

🙄

You can't safely anesthetize someone with opioids in their system.

Say that again....

 

[GasEmDee]

🙄

Say that again....

It was sarcasm.

Heroin is an opiod. It is not a CNS stimulant like cocaine. People are often confused on that point. Inducing someone who recently had heroin is like inducing someone who recently had any other opiod.

 

[Planktonmd]

Now damn it, that was a lot of typing. Please say that I passed!🙂

I would have said: "In coronary artery spasm you would see ST elevation"

So, if you have a young guy who could be doing cocaine and you see ST elevation think spasm and treat as such( Nitroglycerine + Calcium channel blockers), beta blockers may not be a good idea here.

 

[ProRealDoc]

Triggering of myocardial infarction by cocaine.

Mittleman MA, Mintzer D, Maclure M, Tofler GH, Sherwood JB, Muller JE.
Institute for Prevention of Cardiovascular Disease, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA. [email protected]


Comment in:

• Circulation. 2000 Jul 11;102(2):E17.

Abstract

BACKGROUND: Cocaine has been implicated as a trigger of acute myocardial infarction in patients with and those without underlying coronary atherosclerosis. However, the magnitude of the increase in risk of acute myocardial infarction immediately after cocaine use remains unknown. METHODS AND RESULTS: In the Determinants of Myocardial Infarction Onset Study, we interviewed 3946 patients (1282 women) with acute myocardial infarction an average of 4 days after infarction onset. Data were collected on the use of cocaine and other potential triggers of myocardial infarction. We compared the reported use of cocaine in the hour preceding the onset of myocardial infarction symptoms with its expected frequency by using self-matched control data based on the case-crossover study design. Of the 3946 patients interviewed, 38 (1%) reported cocaine use in the prior year and 9 reported use within the 60 minutes preceding the onset of infarction symptoms. Compared with nonusers, cocaine users were more likely to be male (87% vs 67%, P=0.01), current cigarette smokers (84% vs 32%, P<0.001), younger (44+/-8 vs 61+/-13 years, P<0.001), and minority group members (63% vs 11%, P<0.001). The risk of myocardial infarction onset was elevated 23.7 times over baseline (95% CI 8.5 to 66.3) in the 60 minutes after cocaine use. The elevated risk rapidly decreased thereafter. CONCLUSIONS: Cocaine use is associated with a large abrupt and transient increase in the risk of acute myocardial infarction in patients who are otherwise at relatively low risk. This finding suggests that studying the pathophysiological changes produced by cocaine may provide insights into the mechanisms by which myocardial infarction is triggered by other stressors.

PMID: 10351966 [PubMed - indexed for MEDLINE]Free Article

Publication Types, MeSH Terms, Substances, Grant Support

 

[sevoflurane]

It was sarcasm.

Boops....
My bad, wasn't sure.

Vasospasm can give you REAL ST elevation in the right patient. Supply/demand. Say you have a high pressure gradient downstream courtesy of a fatty plaque from nicotine and poor health habits. Suddenly you can't overcome that same pressure gradient to supply the myocardium at risk. If it is not controlled via CCB or other modality (collateral circ.), then you are at risk for developing ST elevation. Vasospasm can be so bad that your blood flow halts to just a trickle. Think of radial artery vasospasm. Not much different.

 

[drccw]

check vitals... if they don't seem to be out of wack (ie HR >100, BP >180/100) do the case. Propofol, LMA, Sevo. Routine ASA monitors.

Remind him to quit using coke...

Oh yeah. If he does get ST elevations, kid may end up getting a boatload of aspirin, Plavix, heparin, etc maybe leading up to a cardiac cath. No spinal.

this is not a good reason for no spinal....
Unless you plan on cathing the patient before the spinal....

 

[Noyac]

to the OP, why did they do the test? they did it for a reason, ie, they wanted to know if he was on cocaine so they could cancel if he was.

It's a hypothetical case.

But lets say the surgeon had a reasonable suspicion.

Should you do the case if the guy isn't acutely "high"?

 

[Noyac]

What have I achieved from not doing this case and rescheduling it? Perhaps a decrease in morbidity and mortality. This patient is at high risk from a CVS point of view. He needs to be off these street drugs and if his BP is high, it needs to be controlled. Further, if he stated he quit 3 days ago...I would still assume he's lying a little bit.

Reschedule when utox is negative. Tell him that otherwise he can die.

What have you achieved from canceling is exactly the question one must ask. Will he quit the coke to have his surgery? Maybe and maybe not. What if you keep canceling and if becomes incarcerated? Now you have got a bigger problem. Just a thought.
What if he took off of work for the 6 weeks to have the surgery and now he is canceled and waiting a normal UTOX. What if he just did it once while in Vegas on a bachlor party?

Is he really a higher risk from a CVS stand point?

Would he really die? Or would he do just fine?

 

[Arch Guillotti]

Ask the patient when he used last.

Determine if he is acutely coked up.

Talk to the surgeon.

Put him to sleep, wake him up and move on.

 

[Noyac]

check vitals... if they don't seem to be out of wack (ie HR >100, BP >180/100) do the case. Propofol, LMA, Sevo. Routine ASA monitors.

Remind him to quit using coke...



this is not a good reason for no spinal....
Unless you plan on cathing the patient before the spinal....

Nice post.

 

[Noyac]

Triggering of myocardial infarction by cocaine.

The risk of myocardial infarction onset was elevated 23.7 times over baseline (95% CI 8.5 to 66.3) in the 60 minutes after cocaine use. The elevated risk rapidly decreased thereafter. CONCLUSIONS: Cocaine use is associated with a large abrupt and transient increase in the risk of acute myocardial infarction in patients who are otherwise at relatively low risk. This finding suggests that studying the pathophysiological changes produced by cocaine may provide insights into the mechanisms by which myocardial infarction is triggered by other stressors.

PMID: 10351966 [PubMed - indexed for MEDLINE]Free Article

Publication Types, MeSH Terms, Substances, Grant Support

This article proves the point I'm headed towards. If you think he did the coke on the way to the ASC (within 60 minutes) then you might have a leg to stand on but if not then his risk is minimal at best.

 

[Noyac]

Good discussion everyone.


Patients who have urine toxicology screens positive for cocaine metabolites are usually considered to be at increased risk for general anesthesia. This perception persists even when these patients do not demonstrate other signs of cocaine toxicity, such as tachycardia, hypertension, or electrocardiographic (ECG) changes. As a result, when these patients present for elective surgery, their procedures are frequently cancelled and the patients must return with negative urine toxicology results before surgery can proceed. This routine cancellation of such patients may be associated with increased costs and inefficient use of resources.

A recent study compared the risks of general anesthesia in patients with positive urine toxicology screens for cocaine to an age-matched cohort whose procedures occurred in the same time frame. In addition to having a positive urine screen, the study subjects had to have an unchanged or normal ECG, have vital signs considered to be normal (or within 10% of those obtained in a recent clinic visit), and be normothermic.

The subjects (40 each in the cocaine-positive and control groups) underwent a standardized general anesthetic. Data were collected from the preoperative evaluation, the intraoperative anesthetic record, and the recovery room record. Some of the data collected included the number of distinct cardiovascular episodes (defined as a 30% change in heart rate or 40% change in blood pressure compared to preoperative controls), the number of cardiovascular episodes that required vasoactive drug treatment, and the number of episodes of ST segment depression or elevation.

The control subjects were statistically significantly older (42.3 years compared to 36.6) and statistically significantly heavier (86 kg versus 82 kg), but the distribution of surgical procedures was similar (mostly orthopedic). Preinduction vital signs were not different between the groups. The results of the study are shown in Table 1 and Table 2. Table 2 shows intraoperative data only.

Table 1. Intraoperative and postoperative data measurements. All results are mean (sd). No significant differences were noted in any variable measured. Modified, from Hill GE, Ogunnaike BO, Johnson ER. General anaesthesia for the cocaine abusing patient. Is it safe? Br J Anaesth. 2006; 97:654-657.



Cocaine groups (n=40)

Control group (n=40)

P value

End-tidal sevoflurane concentration (%)

2.02 (0.5)

1.95 (0.3)

0.45

Intraoperative crystalloid volume infused (mL/h)

722 (63)

698 (71)

0.11

Episodes of ST segment elevation/depression > 1 mm

0

0

-

Postanesthesia recovery room stay (min)

58.5 (5)

61.3 (8)

0.06

Intraoperative body temperature (°C)

35.8 (0.6)

35.6 (0.6)

0.14

Total fentanyl dose (mcg)

202 (20)

210 (19)

0.07

Duration anesthesia (min)

114 (19)

118 (21)

0.37



Table 2. Fisher's exact test (two-tailed) demonstrating the distribution frequency of decreased mean arterial blood pressure (MABP) episodes (-40% when compared with preanesthetic induction baseline values) for the cocaine and control groups. Modified, from Hill GE, Ogunnaike BO, Johnson ER. General anaesthesia for the cocaine abusing patient. Is it safe? Br J Anaesth. 2006; 97:654-657.



Number of episodes
(MABP - 40% baseline) per patient

0

1

2

Cocaine group (n=40)

Number (%) of patients



37 (92.5)



3 (7.5)



0 (0)

P value=0.28







Control group (n=40)

Number (%) of patients



36 (90)



4 (10)



0 (0)

The results also showed the number of distinct cardiovascular episodes did not differ and that intraoperative vasoactive drug requirements were not different between the groups. Phenylephrine was required three times in each group, and labetalol was never used. No heart rate changes of greater than 30% of baseline were recorded, and no dysrhythmias were reported. Finally, no complications were reported by patients, who were followed-up with a 24-hour postoperative telephone call.

The authors concluded that patients who have positive urine screens for cocaine metabolites but are without signs of cocaine toxicity can undergo general anesthesia without increased risk compared to age- and procedure-matched controls. This study, however, is underpowered to determine the risk of rare events such as death.

References

Hill GE, Ogunnaike BO, Johnson ER. General anaesthesia for the cocaine abusing patient. Is it safe? Br J Anaesth. 2006; 97:654-657.
Stoelting RK, Dierdorf SF. Anesthesia and Co-Existing Disease. 4th ed. New York: Churchill Livingstone; 2002:642-643.

 

[Noyac]

BTW, how many of you have used cocaine to topicalize the nares for an awake FOI? Or how many ENT surgeons still use cocaine for nasal surgery? Not many but they did in the past.

 

[2win]

BTW, how many of you have used cocaine to topicalize the nares for an awake FOI? Or how many ENT surgeons still use cocaine for nasal surgery? Not many but they did in the past.

Nobody in the last year at my gig because they took it out - "abuse potential"

 

[sevoflurane]

BTW, how many of you have used cocaine to topicalize the nares for an awake FOI? Or how many ENT surgeons still use cocaine for nasal surgery? Not many but they did in the past.

For nasotracheal intubations?

If healthy and w/o significant pulm/cardiac issues I use it all the time:

Vasoconstrictor + epi = less % of heme on your lens
Cocaine is a fast LA and ideal for sphenopalatine block with directed pledgets.
If they are not snorting it.. not a big deal. IMHO.
Good application for the drug.

I usually add peace pipe 4% to the mix + AW blocks for really difficult ones.

 

[sevoflurane]

AW blocks for really difficult ones.

Funny though.. I have not used a spinal needle for a glossopharyngeal for a long time....🙄

 

[Surfer]

that study only had 40 patients in each group. not nearly enough power. i still wouldn't do it, but again, most surgeons wouldn't either. if my colleague wants to do the case, more power to him, i'll do somebody else. its not my fault if you're a total ***** and do cocaine before your hernia surgery. i'm not going to put my license and career and malpractice on the line for that scenario. come back in 3 weeks clean.

 

[sevoflurane]

that study only had 40 patients in each group. not nearly enough power. i still wouldn't do it, but again, most surgeons wouldn't either. if my colleague wants to do the case, more power to him, i'll do somebody else. its not my fault if you're a total ***** and do cocaine before your hernia surgery. i'm not going to put my license and career and malpractice on the line for that scenario. come back in 3 weeks clean.

I know you are in residency dude, but in PP, those are the last things you want your partner to say. No harm intended 🙂.

 

[fakin' the funk]

Thanks for the laugh!

 

[fakin' the funk]

that study only had 40 patients in each group. not nearly enough power.

Dude, you can't just say "not nearly enough power."

Power is the likelihood of NOT making a false-negative conclusion regarding a certain hypothesis, which in this case appears to relate to detecting adverse intraoperative events requiring intervention.

The authors state the study isn't powered to detect rare events like intraoperative MI's.

Whether or not is was powered to achieve its stated goal -- well, you'd have to see their calculations.