手術前篩查所有患者是否使用大麻：指引

Jake Remaly /2023 年 1 月 9 日/Medscape 醫學新聞

 

根據新的醫學指引，如果您吸煙、吸電子煙或吸食大麻，您的麻醉師應該在您接受外科手術之前知道。

根據美國區域麻醉和疼痛醫學協會 (ASRA) 的建議，應詢問所有接受區域或全身麻醉手術的患者是否、多久以及以何種形式使用該藥物。

原因之一：該組織表示，經常使用大麻的患者在手術後可能會出現更嚴重的疼痛和噁心，可能需要更多的阿片類鎮痛劑。

該組織表示，該協會的建議——上週發表在《區域麻醉和止痛藥》上——是美國第一份涵蓋與手術相關的大麻使用的指引。

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可能的交互作用

近年來大麻的使用有所增加，研究人員一直擔心該藥物可能與麻醉相互作用並使疼痛管理複雜化。 然而，根據新指引的作者，很少有研究評估大麻和麻醉劑之間的相互作用。

「隨著普通人群中醫療和休閒大麻使用率的上升，麻醉師、外科醫生和周術期（即Peri=”Around”手術，關於術前、術中及術後這段時間的醫療照護；國內有人稱為手術全期）醫生必須了解大麻對生理的影響，以便提供安全的周術期照護」，該指引說。

「在手術前，麻醉師應該詢問患者是否吸食大麻——無論是藥用還是娛樂用——並準備好在某些情況下可能會改變麻醉計劃或延遲手術」，ASRA 主席兼指引資深作者醫學博士Samer Narouze，在有關建議的新聞稿中說。

儘管一些患者可能會使用大麻來緩解疼痛，但研究羉顯示，「經常使用大麻的人在手術後可能會有更多的疼痛和噁心，而不是更少，並且可能需要更多的藥物，包括阿片類藥物，以控制不適」，俄亥俄州 Cuyahoga Falls 的西儲醫院止痛醫學中心的主席Narouze說道。

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嘔吐、心臟病發作的風險

新建議是由 13 名專家組成的委員會制定的，其中包括麻醉師、慢性疼痛醫生和一名患者權益倡導者。 加州大學爾灣分校醫學院麻醉學副主席、醫學博士 Shalini Shah 是該文件的主要作者。

21 項建議中有 4 項被歸類為 A 級，這意味著遵循這些建議有望帶來可觀的收益。 這些建議是在手術前篩查所有患者；對手術時精神狀態改變或決策能力受損的患者推遲擇期手術；就大麻使用可能影響術後疼痛控制的可能性向頻繁、重度使用者提供諮詢；並就使用大麻對未出生嬰兒的風險向孕婦提供諮詢。

作者引用了一些研究來支持他們的建議，其中一項研究顯示，長期使用大麻與術後噁心和嘔吐的發生率增加 20% 有關，這是手術患者的主要抱怨。其他研究顯示，大麻的使用與手術後更多的疼痛和阿片類藥物的使用有關。

其他建議包括，由於心臟病發作的風險增加，患者吸食大麻後至少延遲擇期手術 2 小時，並考慮在手術期間對經常吸食大麻的人調整通氣設置。 研究顯示，吸食大麻可能是心肌梗塞的罕見誘因，並且與氣道炎症和自我報告的呼吸道症狀有關。

儘管如此，該指引指出，鑑於缺乏支持這種做法的證據，醫生不應進行普遍的毒理學篩查。

他們說，作者沒有足夠的信息來就減少手術前使用大麻或在手術後調整使用大麻的患者的阿片類藥物處方提出建議。

美國疼痛醫學委員會主席、醫學博士 Kenneth Finn 對新指引的發布表示歡迎。 芬恩在科羅拉多州科羅拉多斯普林斯的斯普林斯康復中心執業，他編輯了一本關於大麻在醫學上的教科書，並創立了國際大麻科學與影響學院。

「絕大多數醫療提供者真的不知道大麻及其對人體的影響」，芬恩說。

一方面，它可以與許多其他藥物相互作用，包括華法林（Warfarin，又名可邁丁或滅鼠靈，是一種只可口服的抗凝血素，學名為芐丙酮香豆素，一般都以芐丙酮香豆素鈉來儲存及處方）。

指引的合著者 Eugene R. Viscusi 醫學博士、費城托馬斯杰斐遜大學 Sidney Kimmel 醫學院麻醉學教授強調，雖然大麻可能被認為是「天然的」，但不應將其與製成藥物區別對待。

Viscusi 告訴 Medscape 醫學新聞，大麻和大麻素代表「一類非常有效且具有藥理活性的化合物」。 在研究人員繼續評估大麻化合物可能產生的醫學有益作用的同時，臨床醫生也需要意識到其中的風險。

「文獻不斷湧現，雖然我們總是對好消息抱有希望，但作為醫生，我們需要非常了解潛在風險，尤其是在手術等高風險情況下」，他說。

 

Shah 曾為開發醫療設備和藥物的公司提供諮詢服務。 Finn 是教科書「醫學中的大麻：一種基於證據的方法」（Springer）的編輯，他為此收取版稅。

Reg Anesth Pain Med。 2023 年 1 月 3 日在線上發布，全文。Medscape 醫學新聞 © 2023

引用此：在手術前篩查所有患者是否使用大麻：指引 – Medscape – 2023 年 1 月 9 日

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Screen All Patients for Cannabis Use Before Surgery: Guideline

Jake Remaly/January 09, 2023/ Medscape Medical News

 

If you smoke, vape, or ingest cannabis, your anesthesiologist should know before you undergo a surgical procedure, according to new medical guidelines.

All patients who undergo procedures that require regional or general anesthesia should be asked if, how often, and in what forms they use the drug, according to recommendations from the American Society of Regional Anesthesia and Pain Medicine (ASRA).

One reason: Patients who regularly use cannabis may experience worse pain and nausea after surgery and may require more opioid analgesia, the group said.

The society’s recommendations ― published last week in Regional Anesthesia and Pain Medicine ― are the first guidelines in the United States to cover cannabis use as it relates to surgery, the group said.

Possible Interactions

Use of cannabis has increased in recent years, and researchers have been concerned that the drug may interact with anesthesia and complicate pain management. Few studies have evaluated interactions between cannabis and anesthetic agents, however, according to the authors of the new guidelines.

“With the rising prevalence of both medical and recreational cannabis use in the general population, anesthesiologists, surgeons, and perioperative physicians must have an understanding of the effects of cannabis on physiology in order to provide safe perioperative care,” the guideline said.

“Before surgery, anesthesiologists should ask patients if they use cannabis ― whether medicinally or recreationally ― and be prepared to possibly change the anesthesia plan or delay the procedure in certain situations,” Samer Narouze, MD, PhD, ASRA president and senior author of the guidelines, said in a news release about the recommendations.

Although some patients may use cannabis to relieve pain, research shows that “regular users may have more pain and nausea after surgery, not less, and may need more medications, including opioids, to manage the discomfort,” Narouze, chairman of the Center for Pain Medicine at Western Reserve Hospital in Cuyahoga Falls, Ohio, said.

Risks for Vomiting, Heart Attack

The new recommendations were created by a committee of 13 experts, including anesthesiologists, chronic pain physicians, and a patient advocate. Shalini Shah, MD, vice chair of anesthesiology at the University of California at Irvine School of Medicine, was lead author of the document.

Four of 21 recommendations were classified as grade A, meaning that following them would be expected to provide substantial benefits. Those recommendations are to screen all patients before surgery; postpone elective surgery for patients who have altered mental status or impaired decision-making capacity at the time of surgery; counsel frequent, heavy users about the potential for cannabis use to impair postoperative pain control; and counsel pregnant patients about the risks of cannabis use to unborn children.

The authors cited studies to support their recommendations, including one showing that long-term cannabis use was associated with a 20% increase in the incidence of postoperative nausea and vomiting, a leading complaint of surgery patients. Other research has shown that cannabis use is linked to more pain and use of opioids after surgery.

Other recommendations include delaying elective surgery for at least 2 hours after a patient has smoked cannabis, owing to an increased risk for heart attack, and considering adjustment of ventilation settings during surgery for regular smokers of cannabis. Research has shown that smoking cannabis may be a rare trigger for myocardial infarction and is associated with airway inflammation and self-reported respiratory symptoms.

Nevertheless, doctors should not conduct universal toxicology screening, given a lack of evidence supporting this practice, the guideline stated.

The authors did not have enough information to make recommendations about reducing cannabis use before surgery or adjusting opioid prescriptions after surgery for patients who use cannabis, they said.

Kenneth Finn, MD, president of the American Board of Pain Medicine, welcomed the publication of the new guidelines. Finn, who practices at Springs Rehabilitation in Colorado Springs, Colorado, has edited a textbook about cannabis in medicine and founded the International Academy on the Science and Impact of Cannabis.

“The vast majority of medical providers really have no idea about cannabis and what its impacts are on the human body,” Finn said.

For one, it can interact with numerous other drugs, including warfarin.

Guideline co-author Eugene R. Viscusi, MD, professor of anesthesiology at the Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, emphasized that while cannabis may be perceived as “natural,” it should not be considered differently from manufactured drugs.

Cannabis and cannabinoids represent “a class of very potent and pharmacologically active compounds,” Viscusi told Medscape Medical News. While researchers continue to assess possible medically beneficial effects of cannabis compounds, clinicians also need to be aware of the risks.

“The literature continues to emerge, and while we are always hopeful for good news, as physicians, we need to be very well versed on potential risks, especially in a high-risk situation like surgery,” he said.

Shah has consulted for companies that develop medical devices and drugs. Finn is the editor of the textbook, “Cannabis in Medicine: An Evidence-Based Approach,” (Springer), for which he receives royalties.

Reg Anesth Pain Med. Published online January 3, 2023. Full text

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Cite this: Screen All Patients for Cannabis Use Before Surgery: Guideline – Medscape – Jan 09, 2023