Heavy marijuana users

[TheLoneWolf]

Area I work has very high marijuana use in the community and a portion of these patients I would classify as heavy users ( smoke or vape >3 grams per day), vast majority of users are 0.5-1 g daily.

Among the very heavy users, I had noted a few oddities:

40ish male coming in for ureteroscopy developed severe bronchospasm on pushing propofol, no airway manipulation or moving of patient by surgeon. About 90 kg, received 400 mg. Became rigid and notable myoclonus. Bronchospasm broke with ppv, hard thick secretions removed, LMA placed. TIVA. Rigidity broke about 10 minutes later.

30ish female coming in for hernia, about 90 kg, got 400 mg propofol. LMA placed. Again noted to be quite rigid. Gave additional propofol which broke it in about 3-5 minutes. Got about 600 mg total and NO apnea at all.

30ish female for D&C, about 80 kg, got 400 mg propfol upfront. LMA. Lower extremities rigid and in adduction, couldnt place in lithotomy for about 10 minutes. Additional propofol didnt change this. Again spontaneously breathing despite large dose of propofol, or adjuncts.

No hemodynamic instability in any of the above cases

Our propofol is brand name, no preservatives and no bisulfite like in the generics.



Rigidity and myoclonus noted in the above didnt consistently break with additional propofol, opioids. All had been pretreated with IV lido prior to airway manipulation.

Propofol at our shop is rather weak. Most patienta are dosed about 3-4 mg/kg. We used a generic form in residency and rarely did adults require over 3 mg/kg.

Anyone notice something similar?

Does heavy MJ use really increase the apenic threshold?

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[GassYous]

Huh. Just the other day I put an lma for a d&c in a heavy marijuana user (cannabinoid hyperemesis) but then couldn't put the patient in lithotomy for ten minutes like you said. 30 years old, I had her on prop 300 mcg/kg/min and over a mac of gas. Gave fentanyl 50, 50. I even walked over to raise her legs myself and it felt like she was fighting hard although obviously not awake. Never seen it before. Lma had gone in smoothly with prop 200 in this 90 kg lady. Maintenance was on gas 0.5 and prop 75 with no problems (except typical bloodletting requiring oxytocin, methergine, txa, cytotec) and I was really confused.

 

[coffeebythelake]

Seems like you need more propofol. The myoclonus and rigidity might be a function of relative under dosing, it is well recognized that heavy Marijuana users have significantly higher propofol requirements.

 

[shepardsun]

Tangential to this, but I did an EGD/feeding tube placement yesterday in a patient with cannabinoid hyperemesis- intractable nausea/vomiting and gastroparesis (already s/p neurostimulator). She also continued to smoke MMJ 4-5 times a day, as it was the only thing that helped with her symptoms.

 

[Twiggidy]

While I’m slightly skeptical of the propofol formulation you’re using if those doses are correct, if this is a problem in your area then I would start putting a BIS on these patients during induction and make sure you’re deep enough.
I know it wasn’t mentioned but I know a lot of people who like to throw around ketamine like it’s a wonder drug but people will laryngospasm with Ketamine.
I’m just skeptical because 400mg should knock most people out, including the raging alcoholics. I’ll admit there was a week or so at my facility where I was questioning our propofol because I had old folks on 200-250 mcg/kg/min and their BIS would hang around the 50s-60s and when I ended the anesthetic they would wake up immediately. No one complained of recall but I was worried a couple of times.

 

[narcusprince]

Me thinks they are sprinkling some other things into their joints. Pcp, maybe some lean in the drink?(cough syrup with codeine and loperamide).

 

[nimbus]

I give 30mg of roc and turn on the vent in this situation.

 

[dabears505]

Dude be careful routinely giving 400 mg propofol up front. I can't recall ever giving that much upfront.

 

[sevoflurane]

I live i a state where it is legal. Very common consumption. I have not noticed any increase in complications.
Heavy smokers far outweigh cannabis smoker/vapers as far as complications is concerned.

Popcorn lung- Now that does give me pause.

 

[coffeebythelake]

Dude be careful routinely giving 400 mg propofol up front. I can't recall ever giving that much upfront.

Maybe divided doses

The most I've ever given for an LMA is 7 mg/kg propofol to a 20 year old regular Marijuana user. Kept breathing even after 5 mg/kg. BP didn't budge at all.

 

[Twiggidy]

Maybe divided doses

The most I've ever given for an LMA is 7 mg/kg propofol to a 20 year old regular Marijuana user. Kept breathing even after 5 mg/kg. BP didn't budge at all.

But this is where I would agree with Narcus in that maybe there’s something they’re not telling you. I’m get more concerned about heavy drinkers both young and old, and i get a feeling the ones we label as “heavy MJ smokers” are also drinking quite a bit and probably leave the bit of history out.

 

[deleted162650]

It’s a well known fact that there is cross tolerance between propofol and Funions.

 

[TheLoneWolf]

Maybe divided doses

The most I've ever given for an LMA is 7 mg/kg propofol to a 20 year old regular Marijuana user. Kept breathing even after 5 mg/kg. BP didn't budge at all.

This is pretty much exactly what I'm experiencing. I'm only going this high in these heavy marijuana users and those with uncontrolled reactive airway disease. I agree majority of these users may be into other drugs or drinks.

All of the heavy users I have encountered have formally diagnosed or undiagnosed reactive airway disease and having them "light" is inviting laryngo or bronchospasm, as illustrated in the first case I mentioned.

Otherwise never would use these doses outside this or even heavy users with comorbidities

 

[coffeebythelake]

But this is where I would agree with Narcus in that maybe there’s something they’re not telling you. I’m get more concerned about heavy drinkers both young and old, and i get a feeling the ones we label as “heavy MJ smokers” are also drinking quite a bit and probably leave the bit of history out.

Yeah quite possible. But if they are willing to admit heavy MJ use is there a reason they would hide other substance use?? we can't trust them for their word, I dont know what else can be done.

 

[GassYous]

But this is where I would agree with Narcus in that maybe there’s something they’re not telling you. I’m get more concerned about heavy drinkers both young and old, and i get a feeling the ones we label as “heavy MJ smokers” are also drinking quite a bit and probably leave the bit of history out.

I have 6 feet+ athletes who get downed by a little versed and fent vs these little old ladies from the upper east side that eat 5 of versed and 100 of fentanyl like it's nothing. Prop 2/kilo barely touches their pressure.

 

[chocomorsel]

Dude be careful routinely giving 400 mg propofol up front. I can't recall ever giving that much upfront.

You haven’t been doing this long enough.
My brother is trying to go clean from marijuana and is having serious anxiety.
Of note the reason he decided to quit was because of the past few weeks he’s had bad muscle tension/rigidity related to his heavy marijuana use.
I think marijuana is getting laced with other stuff these days as @narcusprince said.
Or probably always had been but usage has gone up and weird things are being noticed.

 

[chocomorsel]

@narcusprince, welcome back. Where you been?

 

[deleted162650]

maybe some lean in the drink?

But are they sippin’ on da sizzurp?

 

[Twiggidy]

I have 6 feet+ athletes who get downed by a little versed and fent vs these little old ladies from the upper east side that eat 5 of versed and 100 of fentanyl like it's nothing. Prop 2/kilo barely touches their pressure.

Exactly this.....

 

[Twiggidy]

But are they sippin’ on da sizzurp?

 

[Twiggidy]

I think marijuana is getting laced with other stuff these days as @narcusprince said.
Or probably always had been but usage has gone up and weird things are being noticed.

Which is why it should be federally legalized and people would be able to purchase from licensed dispensaries.

 

[Hoya11]

Area I work has very high marijuana use in the community and a portion of these patients I would classify as heavy users ( smoke or vape >3 grams per day), vast majority of users are 0.5-1 g daily.

Among the very heavy users, I had noted a few oddities:

40ish male coming in for ureteroscopy developed severe bronchospasm on pushing propofol, no airway manipulation or moving of patient by surgeon. About 90 kg, received 400 mg. Became rigid and notable myoclonus. Bronchospasm broke with ppv, hard thick secretions removed, LMA placed. TIVA. Rigidity broke about 10 minutes later.

30ish female coming in for hernia, about 90 kg, got 400 mg propofol. LMA placed. Again noted to be quite rigid. Gave additional propofol which broke it in about 3-5 minutes. Got about 600 mg total and NO apnea at all.

30ish female for D&C, about 80 kg, got 400 mg propfol upfront. LMA. Lower extremities rigid and in adduction, couldnt place in lithotomy for about 10 minutes. Additional propofol didnt change this. Again spontaneously breathing despite large dose of propofol, or adjuncts.

No hemodynamic instability in any of the above cases

Our propofol is brand name, no preservatives and no bisulfite like in the generics.



Rigidity and myoclonus noted in the above didnt consistently break with additional propofol, opioids. All had been pretreated with IV lido prior to airway manipulation.

Propofol at our shop is rather weak. Most patienta are dosed about 3-4 mg/kg. We used a generic form in residency and rarely did adults require over 3 mg/kg.

Anyone notice something similar?

Does heavy MJ use really increase the apenic threshold?

Are you also giving versed and fentanyl too?

Sometimes straight propofol can do this.

Max I give is 300. Then put the mask on and give them some 8% sevo for 1-2 minutes. Theyll be cooperative and no airway reactivity.

 

[Twiggidy]

Yeah quite possible. But if they are willing to admit heavy MJ use is there a reason they would hide other substance use?? we can't trust them for their word, I dont know what else can be done.

Depend on where you live nowadays, being an admitted marijuana user gets much less of a side eye than being a heavy drinker. Likewise people hide usage of “other substances” because of how negatively they’re viewed and the treatment they’ll get. You can almost assure yourself that any young person “reacting strange” to an anesthetic who didn’t otherwise mention it probably have something (meth, coke, or even legal barbs, etc) in their system, especially since we don’t routinely drug test

 

[UnbentLaryngoscope]

I frequently include ketamine (0.5-1 mg/kg depending on the patient) as part of my induction for patients that use marijuana heavily. At least in my area, the big problem seems to be airway reactivity in these patients and the bronchodilatory effect of ketamine seems helpful. The patient's are usually well behaved with regard to positioning, etc. as well if they've received ketamine.

A dash of glycopyrrolate helps decrease secretions, and ward off laryngospasm from a stray bit of slobber from the ketamine.

 

[deleted875186]

Are you also giving versed and fentanyl too?

Sometimes straight propofol can do this.

Max I give is 300. Then put the mask on and give them some 8% sevo for 1-2 minutes. Theyll be cooperative and no airway reactivity.

Sevo seems to do the trick when nothing else does. For these people I will turn on sevo pretty quickly after giving prop, 8% works for everyone no matter what. I usually have a second 200 mg stick ready for these people, but usually only give up to 300mg total and try tk just mask them down with sevo, and wait a min or two before LMAing

 

[TheLoneWolf]

Are you also giving versed and fentanyl too?

Sometimes straight propofol can do this.

Max I give is 300. Then put the mask on and give them some 8% sevo for 1-2 minutes. Theyll be cooperative and no airway reactivity.

Rarely give versed. Far cry from residency.

 

[chocomorsel]

Sevo seems to do the trick when nothing else does. For these people I will turn on sevo pretty quickly after giving prop, 8% works for everyone no matter what. I usually have a second 200 mg stick ready for these people, but usually only give up to 300mg total and try tk just mask them down with sevo, and wait a min or two before LMAing

Can I ask why Sevo instead of more propofol? 300 of propofol doesn’t cut it when your patient is >300 lbs and young. Although the suxx helps.
I can’t stand the smell of Sevo and my little hands lead to leaky masks.
I give up to two sticks for the big’uns without blinking.

 

[Twiggidy]

Can I ask why Sevo instead of more propofol? 300 of propofol doesn’t cut it when your patient is >300 lbs and young. Although the suxx helps.
I can’t stand the smell of Sevo and my little hands lead to leaky masks.
I give up to two sticks for the big’uns without blinking.

Inhalers are potent bronchodilators

 

[narcusprince]

So in the special forces community they burn through propofol. 3mg/kg is nothing for these special set of individuals. They are like wolverine...... but sux and gas stop everybody. A few things I always give fent before an lma. I don’t use ketamine or desflurane with lmas. And lastly if someone has a history of ponv and you run tiva all day you deserve to be in the mad house. Tiva the last 30 minutes works as well as running it all day. I been low key lately kind of got a big job these days.

 

[chocomorsel]

Inhalers are potent bronchodilators

Oh you are worried about Bronchospasm. Makes sense. I hardly ever use gas on adults unless I am struggling and can’t get extra propofol.
I give them enough of a slug and everything relaxes.

 

[chocomorsel]

So in the special forces community they burn through propofol. 3mg/kg is nothing for these special set of individuals. They are like wolverine...... but sux and gas stop everybody. A few things I always give fent before an lma. I don’t use ketamine or desflurane with lmas. And lastly if someone has a history of ponv and you run tiva all day you deserve to be in the mad house. Tiva the last 30 minutes works as well as running it all day. I been low key lately kind of got a big job these days.

We’ll go ahead brother man.
Good for you. Leave us little people behind.
Good for you.

 

[deleted875186]

Can I ask why Sevo instead of more propofol? 300 of propofol doesn’t cut it when your patient is >300 lbs and young. Although the suxx helps.
I can’t stand the smell of Sevo and my little hands lead to leaky masks.
I give up to two sticks for the big’uns without blinking.

Sevo works better than prop to keep people from reacting, plus I’m going to use it for maintenance anyway, plus anecdotally the sevo and prop are very synergistic so it seems to get people calmed down better than prop. Plus, after the LMA is in, that bolus of prop is going to wear off.

 

[chocomorsel]

Sevo works better than prop to keep people from reacting, plus I’m going to use it for maintenance anyway, plus anecdotally the sevo and prop are very synergistic so it seems to get people calmed down better than prop. Plus, after the LMA is in, that bolus of prop is going to wear off.

Between the time I push propofol to the time I place an LMA is pretty much 1 minute I would guess? I don’t ventilate LMAs. Nothing has worn off yet. Unless again, I struggle.

These days I ventilate no one before intubation. Ain’t nobody got time for that. Used to be in a super fast practice and learned to not ventilate. Then went back to it after I changed jobs. Then Covid came.

Fent, prop, suxx, tube everyday.

 

[Hoya11]

Rarely give versed. Far cry from residency.

me too. but for these young folks with high requirements, its not going to burn you in the PACU

multimodal anesthesia is better than just bombing the system with sky high doses of one agent

 

[deleted697535]

I give 30mg of roc and turn on the vent in this situation.

I do that in every situation

 

[deleted697535]

Between the time I push propofol to the time I place an LMA is pretty much 1 minute I would guess? I don’t ventilate LMAs. Nothing has worn off yet. Unless again, I struggle.

These days I ventilate no one before intubation. Ain’t nobody got time for that. Used to be in a super fast practice and learned to not ventilate. Then went back to it after I changed jobs. Then Covid came.

Fent, prop, suxx, tube everyday.

Sux to everyone? I mean sure, why not but honestly theres so many other ways without that nasty drug
Remi, priming dose of roc


LMA insertion for reasonably healthy person - 1-2mcg/kg remi or just plain old fent, 10mg roc, 1-2mg/kg prop. Sits beautifully, vents easy every time. theres plenty research on this. Give roc with lma's! No apnea, no need to reverse

 

[chocomorsel]

Sux to everyone? I mean sure, why not but honestly theres so many other ways without that nasty drug
Remi, priming dose of roc


LMA insertion for reasonably healthy person - 1-2mcg/kg remi or just plain old fent, 10mg roc, 1-2mg/kg prop. Sits beautifully, vents easy every time. theres plenty research on this. Give roc with lma's! No apnea, no need to reverse

Sux to the ETT unless contraindicated. No relaxer for LMAs. So far so good. Cases can be fast, and don't have easy access to Suga. Use a little roc to defasciculate in most cases. Depending on how mean I am feeling that day.

 

[midazzoler]

https://www.anesthesiologynews.com/Clinical-Anesthesiology/Article/10-19/Regular-Marijuana-Use-Changes-Anesthesia-Needs/56086?sub=36F3CFDB6E5DCB6B427D1D3E23351E11EAEBB4459197186048A5C7FE69&enl=true&dgid=X3676465&utm_source=enl&utm_content=4&utm_campaign=20191031&utm_medium=title

 

[TheLoneWolf]

Cannabis Use Disorder and Perioperative Complications

This cohort study examines whether cannabis use disorder is associated with increased risk of perioperative complications among adult patients after major elective inpatient surgery.

jamanetwork.com

In a surprise to no one ...but actually backed by data now

 

[TheLoneWolf]

Had a 70+ year old dude smoking "16 joints a day" who came for a hernia surgery with an LMA at a mac of 1.3 with all standard meds. Midcase, surgery tech noted he was rhythmically tapping his toes against her Mayfield.

Real questionable guy who one could label as a polysubstance abuser for radial ORIF. Mac of 1.3 and heavy opioid induction, as soon as surgeon applies chlorhexidine to his arm, the patient bent his knees up to his chest.

 

[Simba1711]

I gave 750 of propofol the other day to place an Lma. 28 yo 6 feet and 125 kg . Blood pressure never budged and he never went apnic. Reacted a bit when I placed the Lma. He told me as the propofol was going in that it reminded him of ketamine. In hindsight I should have added sevo or gave him a small dose of sux to reduce the amount of propofol.

 

[nimbus]

He told me as the propofol was going in that it reminded him of ketamine.

😂

 

[sakata8242]

Had two cases where we had refractory hypertension (nothing dangerous, just higher than would be expected given the patient and the depth of anesthesia) in heavy MJ users. One of them laryngospasmed almost immediately when we tried to mask him following a large induction dose of propofol. He then maintained a BP of around 150/80 for the entire duration of the case, despite running him at over 1 MAC of sevo and loading him up with narcotics. Was able to find a couple small case reports describing similar issues in heavy users.

 

[zizzer]

Your experience sounds like mine. Insane propofol doses required. Awareness isn't an issue, but movement, rigidity, etc are. Intubation and NMBs solves the problem.

 

[pgg]

Had some young knucklehead come in on call the other night for an I&D. Healthy 20-something male. Only question was how soon after surgery he could smoke some weed. NPO but I tubed him anyway.

Hands down the thickest, most copious, nastiest airway secretions I've seen in I can't remember how long. After emergence and extubation the volumes of snot and goo he was coughing up and just spitting out onto his chin and chest were ridiculous. I put an O2 mask on him just so the crap he spit up would just be confined to his face.

 

[PpfSuxTube]

Hands down the thickest, most copious, nastiest airway secretions I've seen in I can't remember how long. After emergence and extubation the volumes of snot and goo he was coughing up and just spitting out onto his chin and chest were ridiculous.

Sounds like my toddler

 

[PpfSuxTube]

Insane propofol doses required.

You better crack about 5 vials for me right now buddy...