vlessides/Zhang-2021ASRA; ~843 words

Lake Buena Vista, Florida – Although more North Americans than ever may be using cannabis,

exposure to the substance does not seem to affect major surgical outcomes, according to the

results of a large cohort study.

A team of Canadian researchers concluded that routine cannabis use does not impact a

composite outcome of respiratory arrest/cardiac arrest, intensive care unit admission, stroke,

myocardial infarction, and mortality during hospital stay.

“Cannabis contains cannabinoids which can interact with neurotransmitters, thereby

creating potential drug interactions in the perioperative period,” said Betty Huiyu Zhang,

DEGREE, TITLE at McMaster University in Hamilton, Canada. “Pre-clinical studies also

indicate the potential for such cardiovascular complications as arrhythmias and blood pressure

changes.

“Smoking cannabis can also cause airway hypersensitivity, leading to an increased risk of

laryngospasm and respiratory obstruction in the postoperative period,” she continued. “Smaller

retrospective studies have suggested that cannabis may be associated with increased propofol

requirements for induction and sedation.” Other research has found a potential link between

cannabis use and perioperative analgesic challenges, as well as greater postoperative opioid

consumption and higher pain scores in the post-anesthesia care unit.

Nevertheless, most of the existing literature comprises case reports, case series, and small

retrospective cohort studies, which motivated Zhang and her colleagues to evaluate the effect of

cannabis on perioperative outcomes using a large patient cohort. With that in mind, they captured

data from 1,818 surgical patients presenting to the institution between January 2018 and March

2019 (those undergoing monitored anesthetic care were excluded from the analysis). Cannabis
users were identified by self-disclosure at their preoperative visit and were subsequently

stratified into medicinal and recreational users.

Multiple logistic regression was used to adjust for a number of potentially confounding

baseline variables, including age, sex, BMI, smoking status, other recreational drug use, surgical

setting (inpatient vs. ambulatory), type of surgery, and type of anesthesia.

In a presentation during the 46th Annual Regional Anesthesiology and Acute Pain

Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (abstract

1875), Zhang noted that 606 patients preoperatively reported cannabis use, while the remaining

1,212 served as controls. The total prevalence of reported cannabis use was 4% (606/15,048).

For the propensity score-matched analyses, 142 patients were excluded due to missing

information, yielding a final cohort of 524 cannabis users and 1,152 controls. No difference was

found between groups with respect to the study’s primary endpoint: seven cannabis users (1.2%)

experienced the composite outcome of respiratory arrest/cardiac arrest, intensive care unit

admission, stroke, myocardial infarction, and mortality during hospital stay, compared with 11

controls 0.9%), yielding an odds ratio of 1.06 (95% confidence interval: 0.23-3.98).

Interestingly, although cannabis users were found to experience a greater incidence of

arrhythmias than were controls (2.7% vs. 1.6%; p=0.15), along with a decreased incidence of

PONV requiring treatment (9.6% vs. 12.6%; p=0.08), these differences were not statistically

significant. The incidence of severe pain during recovery was also comparable between groups,

affecting 30.9% of cannabis users and 33.5% of their counterparts who did not use cannabis

(p=0.31).

“More rigorous study should be designed to examine these outcomes,” Zhang noted.
 As the researchers discussed, the study represents the largest single-center effort

examining regular cannabis use in average doses; previous database studies have relied on the

diagnosis of cannabis use disorder, which indicates heavy and/or inappropriate use of the

substance. Nevertheless, the analysis was not without its shortcomings, which included self-

reporting of cannabis use (which may create under-reporting), the researchers’ inability to

quantify the amount, duration, or type of cannabis use, and a lack of categorization of other

recreational drug use.

Such limitations notwithstanding, the investigators were otherwise comfortable with the

findings. “Our results do not demonstrate a convincing association between self-reported

cannabis use and either major surgical outcomes or pain management,” Zhang explained. “Based

on the existing literature, it's appropriate to make perioperative decisions based on considerations

of dose, duration, and indication of use as suggested by recent guidelines.”

Marco Echeverria-Villalobos, MD told Gastroenterology & Endoscopy News that the

primary challenge in studies such as this is accurately estimating the percentage of cannabis

users.

“Despite the wide use that cannabis or cannabinoids have as recreational or medical

drugs, the percentage of patients that can be identified preoperatively as recreational or medical

cannabis users by self-disclosure is still very low (4%), as we can observe in studies that have

included larger sample sizes [Int Orthop. 2019;43:283–292],” commented the Assistant Professor

Of Anesthesiology at The Ohio State University Wexner Medical Center in Columbus, Ohio.

“This continues to be an important limiting factor of studies that seek to accurately estimate the

real impact of cannabis use on perioperative outcomes.

 “Retrospective observational studies using secondary data repositories are likely to

identify a higher percentage of cannabis users who undergo major or minor surgical procedures

and show different results from those revealed in the study by Zhang and colleagues,”

Echeverria-Villalobos continued. “It would also be interesting to study perioperative outputs

comparing cohorts of cannabis users and cohorts of patients with cannabis-abuse disorders, using

secondary data repositories.”

Zhang and Echeverria-Villalobos disclosed no relevant conflicts of interest.

###

Betty Huiyu Zhang, DEGREE

TITLE
McMaster University
Hamilton, Canada
shanthh@mcmaster.ca

Marco Echeverria-Villalobos, MD
Assistant Professor Of Anesthesiology
The Ohio State University Wexner Medical Center
Columbus, OH
614-293-3559
marco.echeverriavillalobos@osumc.edu