In the context of increasing legalization of cannabis and an expanding practice of oral surgery, issues of anesthesiologic safety are acquiring strategic significance for clinical practice.
This analytical review examines the results of a recent study from the oral and maxillofacial surgery clinic of the University of Washington, dedicated to the influence of regular cannabis use on the total dose of propofol during third-molar extraction, and discusses practical implications for preoperative assessment and anesthesiologic planning.
The study included 49 adult patients who underwent third-molar extraction under intravenous general anesthesia, and demonstrated a statistically significant association between the frequency and duration of cannabis use and the total dose of propofol; patients who used cannabis several times a day for at least two–three years required 55% more propofol compared with nonusers.
Specific total dose values were 262 mg in high-frequency long-term users, 216 mg in less frequent long-term users and 169 mg in less frequent short-term users — magnitudes that are clinically significant when planning induction and maintenance of sedation.
Preoperative assessment should include a detailed history of cannabis use — frequency, duration, route of administration and last use — since these parameters correlate with altered pharmacodynamic sensitivity to propofol.
Practical recommendations for the anesthesiologist: consider titration of induction and maintenance propofol dose to clinical effect, use continuous monitoring of depth of anesthesia (e.g., BIS when indicated), capnography, hemodynamic and saturation monitoring, and also ensure readiness for adequate ventilation and hemodynamic support in the face of variable anesthetic requirements.
It is recommended to implement stratification of patients by frequency and duration of cannabis use in the preoperative questionnaire of the dental department — this will allow prediction of the initial dose and titration rate, reduce the risk of inadequate sedation or overdose and improve the reproducibility of anesthesiologic protocols.
Standardized preoperative assessment should serve as a bridge between dentistry, anesthesiology and related services — exchange of information about harmful habits, medications and comorbidities will improve anesthesia planning and postoperative management.
A single-center observation in a Seattle clinic limits the external validity of the conclusions due to possible regional specificities of the prevalence and patterns of cannabis use; large-scale multicenter studies are needed taking into account demographics, routes of administration (inhalational, oral), concomitant tobacco use and psychoactive substances.
Additional studies should evaluate mechanisms of altered sensitivity to propofol — pharmacokinetic and pharmacodynamic components, the possible role of cannabinoid system receptors in modulation of the sedative response, as well as the impact on postoperative analgesia and complications.
For dentists and personnel performing anesthesia in ambulatory maxillofacial surgery, key elements are increasing awareness of the impact of chronic cannabis use on propofol dosing requirements, implementation of preoperative assessment protocols and development of educational modules for staff — this will improve predictability of management and patient safety.
Expert commentary: In the context of increasing cannabis legalization clinical practice must adapt by integrating behavioral history into anesthesiologic algorithms, using depth of anesthesia monitoring when necessary and involving multidisciplinary teams to develop reproducible and clinically validated protocols.
The University of Washington study underscores the necessity of including a detailed history of cannabis use in the preoperative evaluation and adapting anesthesiologic approaches when performing intravenous general anesthesia for oral surgical interventions; the strategic goal is to increase the predictability of propofol dosing and patient safety through standardization and further validation of the results.
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