Episode #109 Cannabis Use and Anesthesia Care, Part 2; and Introducing the Emergency Manuals Implementation Collaborative

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. Last week, we started the conversation about considerations for safe anesthesia care for patients who use cannabis. We are going to continue the conversation today.

Before we dive into the episode today, we’d like to recognize ICU Medical, a major corporate supporter of APSF. ICU Medical has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, ICU Medical – we wouldn’t be able to do all that we do without you!”

Let’s get back into the June 2022 APSF Newsletter and return to our featured article today, “Perioperative Considerations of Cannabis Use on Anesthesia Administration” by Dylan Irvine, Tricia Meyer, John Williams, and Jeffrey Huang. To follow along with us, head over to APSF.org and click on the Newsletter heading. First one down is the current issue. Then, scroll down until you get to our featured article today. I will include a link in the show notes as well.

Last week we covered pharmacological considerations of cannabis as well as the preoperative and intraoperative considerations for patients who use cannabis. It’s time for a quick review before we discuss the postoperative considerations. Check out Table 2 in the article which covers the perioperative considerations of preoperative cannabis use on anesthesia administration and postoperative pain management. Here we go.

Preoperative considerations include the following:

• Assess for signs of cannabis intoxication.
• Obtain comprehensive history of product composition, history of adverse effects, dose consumed, effects caused by missed doses, and the time since the last exposure.
• Evaluate for coagulation dysfunction which may include PTT, INR, and platelet function tests.
• Consider delaying elective surgeries following acute patient consumption of cannabis.

Once we get into the operating room, here are some of the intraoperative considerations:

• Preoperative cannabis use may lead to tolerance to sevoflurane
• Be vigilant when administering sympathomimetics and beta-blockers to patients who use cannabis.
• Patients may be at increased risk of airway hyperactivity.

Now, we made it out of the operating room. Postoperative considerations include:

• Keep in mind that patients are more likely to report higher postoperative pain scores and have increased analgesic requirements.
• Monitor patients closely for signs of cannabis withdrawal. Signs of withdrawal may be anger, decreased appetite, malaise, irritability, feelings of depression, abdominal pain, nervousness/anxiety, chills, sweating, insomnia, nightmares, and tremors.

Let’s dig a little deeper into the postoperative considerations. Postoperative pain management may be difficult for patients who use cannabis.  Several studies have revealed that patients who use cannabis are more likely to report higher pain scores, poorer sleep, and have a higher requirement for analgesic medications in the immediate postoperative period compared to non-cannabis users. These patients are good candidates for multimodal analgesia and consideration for appropriate opioid dosing to effectively manage their postoperative pain.

You also need to be on the lookout for withdrawal symptoms which may occur within 1-2 days from the last cannabis use. Symptoms may continue for 1-2 weeks so this is something that will need to be included in the handoff to the team taking care of the patient on the ward. It is important to continue to monitor patients for withdrawal until cannabis use is resumed. Cannabis users may develop postoperative shivering and hypothermia which may be mediated by CB1 receptor activation and is not thought to be related to withdrawal. Cannabis users may also have increased platelet aggregation from activation of CB1 and CB2 receptors on platelet membranes by a high dose of THC.

The authors conclude with this call to action: “Having a better understanding of the possible effects of cannabis use perioperatively can help anesthesia professionals mitigate perioperative risk and better manage postoperative pain in patients receiving anesthesia.”

We made it to the end of the article, and it is time to hear from Meyer once again. I asked her, “What do you hope to see going forward.” This is what she had to say.

[Meyer] “There are several reasons for anesthesia providers to be aware and understand the implications. Marijuana use is increasing. We’ve seen legalization of cannabis in states for medicinal and recreational purposes and this has grown. Increase in Teens vaping with marijuana and a JAMA internal medicine report found use in adults 65 and older increased by 73% over a 3 year period. Our older patients are looking for help with pain, depression, or poor sleep, and other chronic conditions, anything to help alleviate their symptoms. Marijuana is increasing in potency. The level of THC rose from 4% in 1995 to 12% in 2014 in DEA confiscated samples. The higher potency may have negative health consequences.”

[Bechtel] Thank you so much to Meyer for contributing to the show today and highlighting why this is such a relevant topic for practicing anesthesia professionals to help keep patients safe. It is critical to screen patients for cannabis use and be aware of the important considerations that we talked about today.

Before we wrap up for today, the APSF is so excited to announce a new collaboration with the Emergency Manuals Implementation Collaborative. This is an important step towards the APSF goal of no patient harmed by anesthesia care by helping to support sharing knowledge and resources related to emergency manuals including best practices related to implementation and use. You can check it out over at APSF.org by clicking on the Patient Safety Resources Heading. Then, 9^th one down is the Emergency Manuals Implementation Collaborative. Let’s discuss this important resource.  So, what is this resource? The priorities for the Emergency Manuals Implementation Collaborative or EMIC is the adoption and effective use of emergency manuals to improve patient safety. First up, the team is focusing on perioperative care. The goals for the EMIC include to share knowledge and resources to effectively implement and use emergency manuals to be able to manage, debrief, and train for critical events. The EMIC is an impressive team of 500 interprofessional developers, researchers, and users of emergency manuals from around the world.

Let’s talk details now. Emergency manuals, crisis checklists, and cognitive aids are print or electronic materials which may be used by clinicians during crisis situations to be able to act quickly and provide appropriate care. These resources often have supplementary applications for further learning with education or case review. Many of the lessons learned in aviation and other fields have been used to develop emergency checklists in the perioperative area. Keep in mind that this resource is important for everyone on the perioperative healthcare team, not just the anesthesia professional.

Why do we need emergency checklists? Emergency situations are incredibly stressful events, and they may occur in the preoperative holding area, in the operating room, in the postoperative care unit or anywhere patient care is provided. Have you taken care of a patient during a critical event? Did you use an emergency checklist to help with the management? These critical events are often rare which is a good thing, but even with education and training, clinicians may be not be familiar with the management. In addition, the stress of needing to act quickly can harm cognitive performance so emergency manuals serve as a bridge between available knowledge and optimal performance. Another benefit is that emergency manuals or checklists can help to make sure that everyone on the perioperative team is on the same page during key management steps. Studies have shown that the use of OR checklists lead to improved performance during simulated critical events.

You have likely heard of the OR emergency manuals available by Ariadne (air-re-ad-knee) Labs or Harvard, Stanford University, and the Society for Pediatric Anesthesia. There is even more good news since these are available free. If you head over to the EMIC website, you can find these cognitive aids and others in the free tools section. These cognitive aids have been created by anesthesia professionals from around the world. There is also a subspecialty section with checklists focused on obstetrics, pediatrics, thoracic, trauma, neurasthenia, regional anesthesia, and office-based anesthesia. We hope that you will check it out and share it with your colleagues. I will include a link in the show notes as well.

Another great resource is the mobile app, “Pedi Crisis 2.0” that was created by the Society for Pediatric Anesthesia and is available to download on iOS and Android.

Back in 2015, the APSF held an Expert’s Workshop on the implementation of Emergency Manuals. The important take-aways from this workshop included wide recognition of the value of emergency manuals for keeping patients safe and a call to action for a better understanding of the benefits, risks, and optimal implementation strategies as well as a call for the APSF to take a leading role in promoting emergency manuals. And this brings us to 2022 and the top 10 patient safety priorities. The top 3 priorities are culture of safety, teamwork, and clinical deterioration and these are all closely related to emergency manuals.

Before we wrap up for today, let’s dive into the resources available on the EMIC website and we hope you will head over there just as soon as you finish listening to this podcast. The EMIC Website can be used to access all the major available checklists as well as subspecialty practice, and those from around the world. You will also find updated relevant literature and an archive of prior EMIC webinar programs. Do you want to implement emergency manuals at your institution? Check out the video library as a tool to aid in training clinical teams how to use emergency manuals. There is also an implementation toolkit. Here are some of the important steps.

• Obtain the emergency manuals
• Establish goals for use in your organization
• Team training
• Improve care to patients during critical events

The toolkit was created with items that were found to be valuable from a 2-year clinician study of checklist implementation including training materials, presentations, and videos. This study was supported by the Agency for Healthcare Research and Quality that was conducted by Harvard and Stanford. Plus, if you head over to the operating room emergency checklist implementation toolkit, you will find information about the toolkit, the actual toolkit, and you can read stories about successful implementations.

I am going to read one of these success stories now about managing care in acute settings from the EMIC website.

“My vascular case was going very smoothly until my patient decompensated from severe anaphylactic reaction to protamine. Despite being fully aware of the appropriate management and drug doses of such a reaction, all my brain energy went into managing the immediate cardiovascular deterioration. The checklists freed my mind to focus on coordinating the team, our communication, and making sure the patient received the appropriate treatment quickly. Checklists are invaluable in such an acute settings and they helped our patient survive this life threatening situation.” Do you have any success stories from using emergency manuals? You can share them with us by tagging us on twitter @APSForg. We would love to hear from you.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

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Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2022, The Anesthesia Patient Safety Foundation