Good afternoon, and welcome to Day 3 of the AANA Congress. I'm Valerie Diaz, and I'm a member of the AANA's Professional Development Committee. I have a couple of points of housekeeping. The restrooms flank this ballroom for your situational awareness. I'm sure by now you've all been accessing your app and following an agenda, choosing which presentations to attend. So thank you for joining us today. Attendees have until Monday, September 9, 2024, at noon Pacific time, to submit individual session evaluations and the overall conference evaluation. Following this date, you will no longer be able to claim CE credits for annual Congress, so I can't impress upon you enough to please fill out your evaluations as you attend presentations. They'll be available 15 minutes before the close of any presentation, therefore, 15 minutes before the close of this presentation. Also, you can send questions to the speakers via the questions icon in the app following the session. I'll be monitoring for those questions throughout this presentation. If time permits, your questions that you ask will be answered by our speakers live. In-person attendees may also come up to the microphone located on the aisle. Lastly, please mark your calendars. We are looking for speakers for our 2025 Annual Congress in Nashville, Tennessee. If you'd like to speak and share your expertise, the call for abstracts will open on August 14th. Keep your eyes peeled to your email. For more information about submission guidelines, please refer to aana.com. Thank you, Valerie. So my name is Jeff Darna. I am a member of the Professional Development Committee here at the ANA. I'm also the Program Administrator for the University of Southern California. And up here on stage with me today are two of our amazing nurse anesthesia residents, both third years. And the reason they're up on the stage is this is their scholarship project, their capstone project, if you will, that they have been working on for the last two years. Also in the audience, not up on stage, but will be available for questions and answers after this session, is Jake Abel. You'll also see him, it's really bright up here, I know what they mean by you can't see in the dark, will be available and he'll be up on the stage later on actually answering questions but also for the College Bowl later for today. So we have Lauren Destrata and Omar Silva, all three of these gentlemen, professional nurse anesthesia residents, have been working really hard for the last two years to organize an algorithm that can be useful in almost any clinical setting to determine whether it's safe to proceed with surgery or whether somebody needs further testing for cocaine or methamphetamine. So without further ado, here is a simplified decision algorithm to proceed with an elective procedure in patients with a history of cocaine and methamphetamine use. Can we have the slide deck up, please? Thank you. Awesome. Thank you, everyone. So good afternoon. My name is Omar Silva. This is Lauren Destrata. We just want to give a special thanks to our faculty chair, Dr. Darna, and then Jake who will be joining us up here a little bit later. So welcome to our session. We're going to be presenting a simplified decision algorithm to proceed with an elective procedure for patients with a history of cocaine and methamphetamine use. So before we begin, just a few reminders. So the ANA is accredited by the ANCC. So to obtain your CE credits, you have to stay for at least 85% of the session. We'd love to have you here. We also have no financial relationships or commercial interests to disclose, and we will not be discussing any off-label use during this session. So a few learner outcomes for you all. So we'll be discussing the physiological changes and perioperative risks associated with cocaine and methamphetamine use. We'll also be identifying risk stratification tools on patients with a history of cocaine and methamphetamine use. We'll identify the indications for urine drug screening before an elective procedure, and then we'll learn how to apply the algorithm in a clinical setting that we'll show you all about halfway through our presentation. So we want to kind of start with the case study here. Here's Keith Smith. He's probably our typical patient that we'd meet on a Monday morning. You've been off all weekend, having a good time with your friends and family, and you show up to pre-op on Monday morning. You have a 62-year-old male presenting for a left total knee arthroplasty. Has a history of hypertension, insulin-dependent diabetes, had a prior stroke with no residual deficits. He's had a couple surgeries, had a lap coli in 2015 and a terp in 2020. He's on atorvastatin, metformin, Atlantis, metoprolol, and lisinopril. All of his vital signs are appropriate for an elective surgery. Diagnostic workup, we have an ECG, sinus rhythm, no axis deviation. His X-ray is within normal limits, no signs of an acute chest. All of his labs are within normal limits. Pre-op glucose was 85. We get to his social history, and we do have a positive urine drug screen for methamphetamine. He tells us that he lost use eight days ago, so he's still an active user, but has abstained for eight days. And we also have some risk calculators, RCRI, so Revised Cardiac Risk Index. He scores two points on that, puts him at class three risk, so 6.6% elevated risk of a perioperative cardiac event, and his METs are greater than four. So you meet Keith, you talk to him in pre-op. You step away because you don't really know what to do. You didn't know about his MET history, so you ask yourself, do I proceed, delay, or cancel this case? You go talk to a few anesthesia colleagues. You're like, hey, what do you think I should do? You ask three people, get three different answers. Very typical with this kind of patient presentation. You then look to facility policies, protocols, and you find that there's nothing written for the center that you're at. So if you were to proceed, you know that patients with a history of methamphetamine use can be at increased risk of hemodynamic instability. They can present with catecholamine depletion. They can develop intraoperative vasoplasia, where they're not responding to our vasoactive medication. We also know that there are increased morbidity, so they're at higher risk of an intraoperative MI, having a stroke. So you really want to take the time to work these people up. And then you say, do I delay and possibly obtain more workup? And if you get more workup, what are you going to get? So you ask yourself, do I repeat another urine drug screen that likely will be positive based on what he told us? Do I repeat an ECG? And is this patient a candidate? You know, some places are starting to do bedside point of care, TTE. So is this patient a candidate for a bedside echo to assess his current cardiac function? And then lastly, would you cancel this case? So we know that that decision is never taken lightly. Our surgery colleagues do not appreciate when we do that. And then there's other factors to consider as well. We can worsen the patient's outcomes. With this population, we know that they're at high risk of never coming back. So when we cancel a case, we could be canceling it forever, because we lose them to follow up. We also know that canceled cases, after the OR has been prepped, or the patient's been prepped, costs money ultimately. And some of the data out there tells us that canceling cases can cost anywhere, cost a facility anywhere between $5,000 and $10,000 in lost revenue, or just lost expenses from the setup and wasted equipment. Now for some facilities, that might not be a lot of money. But there's places out there, lower reimbursement rates, they kind of operate on margin. So over time, that money really can add up. So why does this matter to us? Why is this important to nurse anesthesiologists and the anesthesia community overall? So for starters, cocaine and methamphetamine use is pervasive. SAMHSA statistics tells us that 5.2 million people in the U.S. regularly use cocaine, and another 2.5 million people regularly use methamphetamine in 2020. And these numbers are growing year over year. So it's more than likely that we all encounter these patients in the clinical setting, and often more times than we actually identify. There's also a survey from the Veterans Health Administration. They put a survey out there to 172 facilities, and found that only 11 of those facilities had formal urine drug screen policies, and then two-thirds of the survey respondents simply said, if we have a positive urine drug screen, we cancel the case regardless. What this tells us is that there's a lot of patients out there in the VA system that probably aren't getting the most up-to-date or care that they deserve simply because we're not practicing, you know, with the latest evidence that's out there. There's also lots of variation with perioperative management, with professional opinions regarding this patient population, and ultimately, practice guidelines are vague. Our own ANA published a substance use policy or practice guidelines towards the end of 2023. A lot of this journal really focuses on opioids and kind of medication-assisted therapy, but when we got to reviewing the document, when we looked at the data or the literature for cocaine and methamphetamine patients, it was pretty thin. So that kind of inspired us to dig deeper and, you know, put more work out there for our community. So this leads us to our research question. So can patients with a recent history of cocaine or methamphetamine use safely receive anesthesia for an elective procedure on the day of surgery compared to patients who do not use cocaine or methamphetamine? So simply said, can we safely anesthetize these patients? And we're going to compare the active users to those who abstain from these substances. Okay. So with all of that said, we set out as a group to want to tackle the inconsistency and variation when it comes to managing patients with a history of cocaine or methamphetamine use. We wanted to create some evidence-based approach that would help to guide anesthesia professionals in the risk stratification and decision-making when it comes to managing this patient population as they present to the elective surgery setting. And to do this, we wanted to draw from already established practices. That is for the use of algorithms. Algorithms like the ACLS algorithm or the difficult airway algorithm are great ways to introduce some consistency into care to hopefully improve patient outcomes. And we hope to want to create an algorithm of our own that we could use to serve this patient population. To achieve this goal, we set out some specific aims. First, we wanted to determine the risk and benefits of administering general anesthesia to this patient population. And really, we're asking ourselves, how safe is it actually to give these patients general anesthesia? Next, we wanted to take a good, hard look at urine drug screen. Currently, urine drug screen is pretty integral in the management of patients from this patient population. And we wanted to ask ourselves, what information are we getting from urine drug screens? And how is this information actually influencing our clinical decisions? And moreover, are there any other tools that we can use to make decisions with this patient population? And we would take the information from these first two aims, and we'd use that to create a clinical decision-making algorithm that we could hopefully disseminate among the community. So key concepts and definitions, defining these concepts were important for adding clarity to our project. And it's also just good for us to have a shared place of understanding. So our first term is hemodynamic instability. This refers to a 40% drop in mean arterial pressure for at least five minutes or for the requirement of a vasoactive medication. Patients with a history of cocaine or methamphetamine use are known to have some hemodynamic instability. So we wanted to explore this, and of course, we wanted to really have a clear definition of what this means, really. Next, we have cocaine and methamphetamine toxicity. This just refers to the adverse effects of both of these drugs when acutely used. We're going to explore this a lot more in our literature review. Next, we have elective procedure. This is a procedure that can be rescheduled. The timing is flexible, and delaying the procedure is unlikely to affect patient outcomes. But with that being said, indefinitely delaying procedures eventually can lead to a poor patient outcome. And I think a pretty prominent example of that is patients with cancerous masses. And last, we have urine drug screening. Urine drug screening is a testing method that uses immunoassay technology to detect drugs or metabolites of interest. And we're going to do a very deep dive on this in a little bit. So this is a very quick overview of our literature review. First, we're going to discuss the effects of cocaine and methamphetamine. Next, we're going to discuss the perioperative outcome data of this patient population when they receive general anesthesia. And then lastly, we're going to take a look at urine drug screens and risk assessment. Our search allowed us to find about 67 articles that we used to help inform our project. And we're, of course, just going to go over our most important ones. Our articles range from very recent and new data from the ambulatory surgery setting and does range to older studies, studies from the emergency trauma setting, as well as bench science. Extrapolating data from articles outside of ambulatory surgery can certainly introduce some problems within our data collection. However, we still do believe that the findings of these studies support our overall recommendations. So first and foremost, what is cocaine and what is methamphetamine? Cocaine is a drug, a chemical. It's actually synthesized from a plant known as Erythroxylum coca. This plant is native to South America, the West Indies, and Indonesia. Methamphetamine, on the other hand, is almost entirely synthetic. It was first synthesized in the early 1900s and actually synthesized from ephedrine. Both of these drugs can be ingested in a variety of different ways. They can be smoked. They can be taken intranasally. They can be injected intravenously. And when taken, they can cause many things to happen within the body. One key one, however, is that both of these drugs cause the buildup of dopamine within the brain, and this leads to a feeling of euphoria. Euphoria is why people like to take these drugs, and it also serves as the basis for why patients get addicted to these drugs. And as Omar kind of mentioned, this is a problem that's growing year over year. So what happens to a person when they take these drugs in the immediate setting? How do our patients actually look? One of the main mechanisms is that both of these drugs cause the blockage of catecholamine reuptake, more specifically norepinephrine. These patients will have excess norepinephrine. They will get sympathetic nervous system activation and overexcitation. So how do these patients actually look? These patients will be tachycardic. They'll be hypertensive. They might be sweating. They might be hyperthermic. They can have some psychotic symptoms, such as agitation and paranoia. And broadly speaking, this list of symptoms is actually fairly nonspecific. It can be described by actually a long list of differential diagnoses. And this is important for our understanding because, of course, we want to know what these patients look like when they're acutely toxic, but we should also understand that, you know, just because they have a history of cocaine or methamphetamine use, toxicity might not be what's actually going on. So it's important for us to, of course, do our due diligence when we work these patients up. So what happens when people take these drugs over the long term? It's very not good. In fact, it affects every single major organ. In the lungs, it can cause distortion of the lower airways, leading to bronchiolitis. In the brain, it can cause psychotic symptoms, predisposes patients to stroke. And in the kidneys, it promotes renal ischemia and ultimately renal failure. So when you have these patients with a history of cocaine or methamphetamine use, it's important to also understand that these systemic effects might also be at play. And with all of that said, what we're most concerned about within anesthesia, of course, is what these drugs mean for the cardiovascular system. Both of these drugs can cause myocyte apoptosis, ventricular remodeling, and lead to cardiomyopathy and heart failure. It promotes arrhythmia. And patients, people that use cocaine and methamphetamine are more likely to experience myocardial infarction compared to those that do not. So for us, we need to really have a good understanding of their cardiovascular health, understand that these patients might have some hemodynamic instability, and we should be very considerate before we decide to put them under general anesthesia. Last thing I want to talk about is catecholamine depletion. The chronic use of both of these drugs lead to the depletion of catecholamines. This is very scary to us because this is what most explains as to why these patients experience refractory vasoplegia when they're put under general anesthesia. So it was very important for us to want to explore this relationship between cocaine and methamphetamine use and catecholamine depletion. Unfortunately, this is just not a very well-studied area, and it's poorly defined, which made our search a little bit difficult. One area we did decide to look at, however, was in addiction studies. Addiction studies that look at this patient population look at dopamine. Cocaine and methamphetamine cause dysfunction and dysregulation of dopamine and dopamine receptors. We found many different studies. One that we found to be a little bit promising was one that looked at the brains of 12 methamphetamine users. And this image right here is actually from that study. So in that study, they gave their subjects methylphenidate. Methylphenidate causes release of dopamine, and they got PET scan images of their brain to evaluate the dopamine activity in their brain. So let's look at these images. The top brain is someone that does not use methamphetamine. They were given methylphenidate. They got the scan. And as you can see in those colored areas, you see a lot of bright orange, bright yellow. And that's indicative of dopamine receptor activity. And that is what normal dopamine receptors look like based on imaging. The second image is someone that uses methamphetamine. However, they've been abstinent from methamphetamine for about one month. And as you can see in their image, it looks actually very different. It's a lot less brightly colored. There's greens and there's yellows. And this is showing us that the dopamine and dopamine receptors have a lot of dysfunction and are partially inactive. And then last, we have that brain at the bottom. This is someone that uses methamphetamine. They've been abstinent from it for about 14 months. And in their image, you actually see a lot of the return of bright coloration. And it actually looks pretty similar to that top brain as well. And that shows kind of a good dopamine receptor function. So I guess you're asking, what is the exact takeaway from this slide? The takeaway is that catecholamine repletion is possible. And catecholamine repletion might be possible after about 12 months of abstinence based on the studies. While it can be a pretty thin association to draw from dopamine receptors within the brain to catecholamine receptors within the autonomic nervous system, I still think we still believe that it paints a understandable idea of what catecholamine repletion might actually be. Great. Thanks, Lauren. So then, as we continue our literature review here, when we went looking for data for methamphetamine, a lot of information out there, and a lot of it was focused on the trauma population. The trauma patients are typically when we encounter these patients very sick and acutely intoxicated. So in this study by Safdari et al. from 2022, they went and did old anesthesia record reviews. And they went looking for patients that were acutely intoxicated, so positive on a urine drug screen for methamphetamine, and who experienced hemodynamic instability intraoperatively. So they identified that as the 40% drop in their MAP, and then plus or minus the use of vasoactive medication throughout the case. They were also looking for a secondary outcome, which was that 30-day risk of cardiac or cerebrovascular accidents. So they took their population and split people up into three cohorts. The first cohort were the patients that went to surgery within 48 hours of that positive urine drug screen. From there, the second cohort was 48 hours to seven days. And the third cohort were patients that went to surgery seven days after testing positive. And what they found here was that the patients who went to surgery within the first 48 hours, so acutely intoxicated, had the most hemodynamic instability intraoperatively. Now, it was kind of more of a wild ride, busier case, not what any of us would enjoy. We want to kind of sit back, let things ride, not have to be pushing pressers, starting drips. So that patient population had the most hemodynamic instability. And of course, as more time went on with the other two cohorts, 48 hours to seven days, and then post-seven days, as more time goes on, the patient clears those active metabolites. They kind of enter the subacute state. Those patients experienced much less hemodynamic instability, way less pressers. But again, all three groups ultimately did just fine. And that's what the data is telling us, that when we look at them in the acute state, they still have the same outcomes as those that are in the subacute state, even though it's more work for us, right? And then ultimately, in their study, again, they were looking for that 30-day increased risk. And none of their study patients had any events of hemodynamic instability. Any instances of cardiovascular or cerebrovascular events. We also looked at more trauma data. And this one, again, looking at the correlation between positive urine drug screens and specifically what are the patient outcomes. So in this study by Satish et al. from 2021, they looked at data from the National Trauma Data Bank and compared the urine drug screen positive for cocaine or methamphetamine to patients that were going for a similar procedure, similar age, that were not positive for drugs at the time. And so they wanted to look to see, is there an association here between the positive urine drug screen and those who were urine drug screen negative? And how does that affect their overall mortality, risk for MI, risk for stroke? And what did they find here? They found that a positive urine drug screen is not predictive of an MI or stroke in the trauma patients. So when we read this study, again, it kind of gave us hope that we were onto something good here. And we ultimately found, again, from this literature, that with appropriate risk stratification, elective surgery can be safe following a positive urine drug screen. Now, with this study, one key thing that they did know is that the trauma population tends to be younger, right? So they reported that the average age for both the cocaine and the methamphetamine subgroups were about 40, 41 years old. So ultimately, we know that 40-year-olds have a lower baseline risk for MI and stroke than patients with more advanced age. That's something to keep in mind as we look at all this data. OK, so let's take a look at cocaine and general anesthesia. There's many articles that describe this relationship. But one that we found to be most promising was one conducted in 2021 by Moon et al. And in this study, they looked at about 358 patients aged 18 to 65, physical statuses of 1 to 3. They divided the patients into two groups, a cocaine positive group and a cocaine negative group. And they administered general anesthesia to both groups. And the study wanted to look at the intraoperative hemodynamics between the two groups. And more specifically, they wanted to evaluate the heart rate and mean arterial pressure. And the findings of this study, interestingly enough, found that the heart rate and mean arterial pressure were essentially equivalent between both groups. You would not be able to tell a patient was cocaine positive or cocaine negative based on their hemodynamics alone. So what is that telling us? It's really telling us that certain patients can safely receive general anesthesia despite having a history of cocaine use or a positive urine drug screen. And we found actually a few other articles that kind of echoed and reiterated these findings as well. So now let's take a look at urine drug screens. First and foremost, there's more than one type of urine drug screen. The one that we most use in the clinical setting is known as the immunoassay. The other one is known as gas chromatography. However, gas chromatography can take up to three days to result. It's much more expensive and thus is a lot less useful for us clinically. So what is the immunoassay? The immunoassay utilizes antibodies that bind to metabolites of interest. In our case, it's cocaine and methamphetamine. The quantity of antibody binding to metabolites will indicate if a sample can screen positive or negative. But it's really unable to give you, you know, an actual level of substance within the urine. Metabolites of cocaine can persist for up to two weeks. For methamphetamine, it's up to six days. And this varies with the chronicity and the amount of use. And essentially, that's all an immunoassay and urine drug screen is really able to tell us. So what is it not telling us? It's really limited in being able to tell us the exact last time they use. It's not really able to quantify their consumption, how much they're taking, how much they're taking, how frequently they're using it. And most importantly, it's not really helpful in determining if a person is actually toxic. Moreover, the routine use of urine drug screens is not free because you add up over time. And waiting for a urine drug screen to result just does lead to procedural delays. With this all said, how is urine drug screen still helpful for us? Still helpful for us in determining if patients have a history of cocaine or methamphetamine use and giving us an understanding if they're still active users because, of course, we'd want to be more considerate of them. And it's also very useful for us when we're trying to work through that toxicity presentation and really work through those differential diagnoses. So because of this limited utility of urine drug screens, we wanted to look in other directions. As I mentioned previously, we're very concerned about what these drugs do to the cardiovascular system. And we thought it important for us to be able to screen patients based on their cardiac risk. And what better way than to do that through cardiac risk calculators? Cardiac risk calculators like the Lee Revised Cardiac Risk Index or the American College of Surgeons Cardiac Risk Calculator are great ways to evaluate cardiac risk in our patients. And frankly, these tools should be used in our everyday practice as they are very well validated. We find these calculators can be useful for us, for this patient population, because we can use them to screen patients as being low or high risk. So despite us finding all this data that shows there's this relative safety profile of patients safely receiving general anesthesia, we actually don't have data that supports giving general anesthesia to patients with this health history while also having risk factors for having a major cardiovascular event. We do understand that these cardiac risk calculators were never intended to be used for this population, but we believe that it still can serve some good utility for us as we work these patients up. And then ultimately, from all of our literature, we kind of broke it down into four key recommendations. So the first one being safety. So from all the literature, we found that anesthesia can be safely delivered or administered to patients with a history of cocaine or methamphetamine use, provided that they are not toxic. Two, evaluation. So every patient interaction with patients with a history of cocaine or methamphetamine use always has to start with that comprehensive physical exam and the thorough social history of what that entails. Again, so asking for periods of abstinence, chronicity of use, time of last use. When we take all of that into consideration, again, we're just doing our due diligence and upholding that first step of safety. Number three, we found that routine urine drug screens have limited utility. As Lauren explained, they kind of give us this binary data or data point of do they have active metabolites or not. Doesn't quantify anything for us. So it should not be used to preclude patients from elective procedures. And then four, risk stratification tools. So like Lauren mentioned, the RCRI, the Revised Cardiac Risk Index, NISQIP, a little bit longer than RCRI but still a valid tool. Tools like these help us risk stratify and assess cardiac risk for our patients and should be applied to this patient population. And without further ado, I present you guys with our perioperative algorithm for patients with a history of cocaine and methamphetamine use. A little bit later in the presentation, we will have a QR code up here where you guys can scan it and get a copy for yourselves. So really this algorithm is the culmination of our doctoral project. It's about 18 months of our work, you know, digging through the literature, going back and forth with our faculty chair, you know, the three of us, you know, bouncing ideas back and forth. We reached out to a lot of our anesthesia colleagues so they could put eyes on it, help us organize it. You know, we went back and forth on colors. But again, we really believe that this final product helps streamline this process and bring together all of the literature that, you know, we've gone through. So I'll kind of walk you guys through the key pathways and then we'll do a couple case studies. We'll come back to Keith Smith that we met earlier to kind of show you guys how we apply these things in the clinical setting. So kind of looking at this first pathway here on the left side. So we always start at the top with the social history, right? So the time of last use, their quantity, duration, frequency. Again, all of that chronicity and periods of abstinence. So key breakdowns here in the algorithm. So we have greater than 12 months and less than 12 months from their last use. So on this left side, we have greater than 12 months. We then proceed to look at toxic signs and symptoms. So if you look there in the bottom center, we've listed some options. So agitation, arrhythmias, diaphoresis, hypertension, tachycardia, all of these signs that can tell us, you know, if a patient could be actively intoxicated when they're presenting in pre-op. Now, these are nonspecific presentations, right? Nonspecific things that can mean a lot of different things. But if we have a patient here with a history of cocaine or methamphetamine use, they don't have that toxic symptomatology, then we can just simply proceed, right? At this point, it's a streamline from assessment to green light to surgery. Because they don't have this presentation, they're already been deemed that they're lower risk and shouldn't have any negative outcomes with anesthesia. On the same side, if they do have the toxic presentation, then we have to go down a urine drug screen. Why do we urine drug screen these patients if they're telling us that their last use was 12 months ago? We know that this patient population lies. It's an unfortunate thing, but it's what we're dealt with as anesthesia professionals. And we have to do our due diligence to figure out, are they acutely intoxicated from these substances, or is it another differential diagnosis that's affecting? Oftentimes, there could be mass endocrine metabolic disorders that they haven't been formally diagnosed with. So this is where the urine drug screen does have a role in letting us know, is it drugs that is our problem, like right in front of me right now, or is it something else that we need to consult another specialty for? And that brings us to the bottom here. We have to do our due diligence to evaluate for differential diagnoses and also kind of weigh that risk-benefit of the presentation to what the elective procedure is. Now when we get the results from that urine drug screen, if it were to be positive, again, patient probably lied to us, which happens all the time, then we would go ahead and have to cancel the elective procedure and bring them back a later date where they can be retested and hopefully test positive, sorry, test negative at that time. So now looking at the other side of our algorithm here, it's where things get a little bit more interesting. Again we go through the same process. You assess the last use, you look for those toxic signs and symptoms. If they're telling you, hey, I used within the last year and they look toxic, we go straight to that urine drug screen. Again, same as the other pathway, if the tox screen is negative, we're looking for those differential diagnoses, letting the surgeon know, hey, you know, we have a data point with the urine drug screen, this is their symptomatology. We either need to evaluate them because they're negative or cancel them because they've tested positive. Because again, the algorithm does not apply to those that are acutely intoxicated. Next one there. So now the other scenario here, you're within 12 months, they have no toxic symptomatology, now we're looking at those cardiac risk calculators, right? So as Lauren explained earlier, we need more data here to help us risk stratify these patients. So we're going to look at tools like the RCRI, it's going to kind of cover their history, cardiac history, neuro history, insulin-dependent diabetes, those six data points that are covered in RCRI quickly help us determine, is this patient high risk or low risk to proceed with the surgery? Again, focusing on their perioperative chances of a cardiac event. So if you look here in the bottom right of the algorithm, we kind of broke it down. So with the RCRI, class 1 and 2 is low risk for us, and then classes 3 and 4 would be high risk, and we would have to kind of address them differently. So back to cardiovascular risk assessment there, the orange box, looking at the high risk patients now, we would urine drug screen these patients. Why? Because their use is much more recent, and we need to make sure that we preclude that there's no chance that these substances are going to affect our anesthetic, right? They're already sick, and we need to make sure that meth or cocaine or any other drugs really are not going to affect the anesthesia that we're about to provide. So if that urine drug screen is positive, again, we cancel the procedure, talk to the surgeon, let them know what's going on, and reschedule them 7 to 14 days out, depending on the drug, and bring them back, again, retest them because they're high risk, and ideally at that point, they will hopefully be negative and can proceed to surgery. Now if they're low risk, right, based on the RCRI, then again, it's kind of that streamlined, you know, pathway down the algorithm, we just quickly green light them to surgery. So here at this point, you know, I kind of bring back the full algorithm. We really find that, you know, I'm sure all of you guys out there start kind of thinking about your patient scenarios when you've recently taken care of a patient with a history of cocaine use, meth use, remind yourself of what that patient was, and start going through the algorithm. Like I said, we'll give you guys a QR code to get this copy yourself, and then let us know if this is working for you. It's still, you know, can always be in development, but now we'll go ahead and go through a couple case studies, one simple one and one more complex with Keith Smith, and show you guys how we applied it. Thank you, Omar, for explaining our algorithm. I think the algorithm is a little bit more helpful and easy to understand when you actually apply it to someone. So let's meet Sarah Jones. She's a 27-year-old female. She tore her ACL skiing, and she's here for a left ACL repair. She has no medical history, no surgical history. Her ACL signs are all normal. Her ECG is normal. One thing, however, is she did admit to using cocaine in college about four years ago. So with that said, let's take a look at how she does on our algorithm. So first and foremost, we take a look at her history of use. We try to determine her frequency of use, her duration, how much she used. But most importantly, we ask ourselves, when is the last time she used? The last time she used was over four years ago. So we go over to the left side of our algorithm. We next ask ourselves, does Sarah look toxic on cocaine? Her vital signs were normal. She's calm. She's not sweating. So while it is a subjective assessment, I think we can easily say that she's likely not toxic. And because of that, she gets to have her surgery. And that's our algorithm. It's pretty simple and easy to use. However, let's try to apply it to a patient that has a little bit more going on. So you guys might think, yeah, she's 27, no-brainer. But let's come back to Keith Smith here, right? So he's 62 years old, more advanced age. His history, so insulin-dependent diabetes, he had a prior stroke, some CAD. We know he's had anesthesia recently, successfully, no issues. But let's come down to the social history again, right? So the urine drug screen is positive for methamphetamine. He told us that he last used eight days ago. And he scored the two points on the RCRI. He's class three. And Mets are four. So let's see how the algorithm does for Keith. So again, we're assessing his last use. We already know that was eight days ago. We're going to proceed to looking for the toxic symptomatology here. So we're looking for the agitation, the arrhythmias, diaphoresis, hypertension, tachycardia. None of that's present. But because of Keith's health history, so the big focus for him is going to be on the RCRI. So when we get to our cardiac risk calculators, right, we know that Keith gets points for the insulin-dependent diabetes, right, and the prior stroke. So Keith here is now class three risk, right? Two points, class three. A little confusing, but that's the way the authors made it. So class three risk, 6.6% elevated risk of having a perioperative cardiac event at some point, you know, in that perioperative continuum. So because Keith is high risk, we need to retest him, right? We kind of know from the data that, you know, with methamphetamine, about seven days, it will kind of clear their system. We go ahead and retest Keith. He told us eight days, remember, and he tests positive again. So because Keith tested positive and he's high risk, we do have to, unfortunately, cancel his procedure. Go ahead and go to the next one. So we cancel him, reschedule him again. Keith is high risk. He's a class three on the RCRI, 6.6%. And unfortunately for Keith, not so much for us, the literature doesn't support high risk patients, right? Everything that we found, again, mostly focused on the trauma population. They're younger, less comorbidities. They're not really working with high risk patients here. So safest recommendation for all of you all and for Keith. So we're going to reschedule him, delay about another seven days until that urine drug screen can come back negative. We would retest at that time. And then, of course, before Keith leaves, we counsel him, the nurses, the surgeon, please abstain from methamphetamine use. Easier said than done. And then we do want to acknowledge that there's variation in clinical practice. And a lot of different professional opinions exist around this patient population. We can only recommend what's best supported by the literature. And that's what we're presenting here to you all today. So some discussion points from our project. So starting with the strengths of our project, we really think that this algorithm improves access to health care for individuals with substance use disorders. This population is often marginalized by social stigma. They feel like they can't be honest with the health care team. A lot of them come in afraid that they're going to be reported to law enforcement. So just build rapport, remind them that's not what's going to happen here today. We just want to keep you safe with anesthesia. We also believe that implementation of the algorithm helps reduce variation in clinical practice. When we kind of bring all the data together and disseminate it out there to the anesthesia community, people have clear, easy resources that we can all hopefully follow to make sure we're all kind of on the same page and making similar clinical decisions. And with that said, it's simple. It's easy to use. And most likely, with very little training or review, people can pick it up, apply it to their patients, and ideally proceed with surgery. Some of the limitations we found. So like Laurent mentioned earlier, we know the risk calculators were not specifically designed for patients with a history of cocaine or methamphetamine use. But again, we need more data for this patient. We can't just rely on that urine drug screen alone to decide if we proceed with surgery or cancel a case. We did have to extrapolate a lot of our data from the trauma literature and then the bench signs that we reviewed with regards to the dopaminergic system and catecholamine repletion. But again, we found from the trauma literature that they come in for surgery after a traumatic accident, acutely intoxicated, and ultimately they do just fine. So we see the correlation there that now in the elective surgery setting, we have time to work them up. We can actually do a more thorough assessment and see that we can pull forward those same positive outcomes from the trauma population into the elective surgery setting. And then lastly, this is a challenging population to study. We were fortunate enough to find a good amount of data out there. But we know and acknowledge that we can't, well, one, we can't encourage drug use to help recruit patients into our studies. And even if we did get them into a study, again, they tend to be the population that doesn't really follow up. It's harder to chase them down to get them to follow up with our study requirements. And so some take-home points for you all. So again, to reiterate, so patients with a history of co-cater methamphetamine use can safely undergo elective procedures with general anesthesia, provided that they're non-toxic. That's what's supported by the literature. It's what many of us already see in our daily practices. We found that urine drug screens are useful, right, as part of that overall risk stratification, but should never be the sole determinant for whether a case proceeds or cancels. We really have to look at more data points, such as the RCRI or the NISQIP, to help us make that decision. Using this simplified algorithm, again, helps us risk stratify and make that clinical decision when we manage patients with a history of co-cater methamphetamine use presenting for the elective procedure. And then lastly, some of our goals with the future research is to continue the project forward, get our algorithm out into some centers that could help us validate the tool, collect more data from what we've created, and hopefully continue to support the anesthesia community and this patient population. So that concludes our presentation. Thank you all for your attention. We'll now have some time for questions. I'd like to welcome Jake up here to help us answer that. And Dr. Darna. And then please, guys, there's a microphone here. I don't know where they have another one set up. So thank you so much for the presentation. If you have a question, please come up to the microphone. I'm going to read, while people are coming up to the microphone, I'm going to read the first question from the virtual session. And that is, how does your algorithm deal with medications that may result in a false positive result on the UDS? So I think this is probably most in reference to dextroamphetamine, also known as Adderall. And Adderall can screen as positive for methamphetamine. Really the only way you can understand that is that you should know if your patients are taking these medications, like Adderall, and know that Adderall actually doesn't lead to hemodynamic instability when taken. And the other thing with other medications and the false positive urine drug screen, you know, it is possible, but again, continues to be highly unlikely. When we look at the urine drug screen data, these urine drug screens are still pretty darn accurate. So the chance of triggering kind of that false positive, again, is pretty low overall. Yeah, please. Hey, guys. I want to say thank you, because all this information, I had a patient the other day that did test positive for cocaine, and we had to cancel. And all these questions did go through my head, like, how was that decision made so fast? So your algorithm. the algorithm that comes up very helpful, but my question is, have you guys introduced this to the clinical settings that you guys have been into, and how has it been received from the people you've been working with? Yeah, I can kind of speak to that one. We have spoken to a lot of our clinical colleagues about this literature, and actually one of the centers, Dr. Safdari is one of the leading researchers on methamphetamine, and so we had obviously conversations with him about it, and we feel that it's very validated, but unfortunately we haven't had like specific conversations about getting the algorithm implemented to the centers, just the fact that they say that the science sounds right and it sounds like it's an accurate tool to be used. I had a patient situation like this recently, and the patient was initially canceled because of a serum positive, and I know this is focusing on the binary nature of a urine drug screen and the limitations of that. Their suggestion was this is a late week cancellation, they brought the patient back after about four days early the next week, tested them again, tested positive, which seemed short-sighted to me given the time frame in which you're going to clear the drug, and then they put you in a bind. You say, well, we made them wait. They say they were abstinent, but you brought them back in, not their fault, you brought them back in within a time frame, they're still going to test positive. I guess that's more of a commentary than a question, but did you look into whether there's some use of a quantitative in a serum drug screen? Is there any data to say like, hey, this is a quantitative test at this level, probably not acute toxicity, at this level, definitely acute toxicity, or how you parse that data? I try, I mean, I was on the line with the lab, like supervisors say, I see this number, what does this mean to you? And they say, well, there's no validation for this in a clinical applicable setting, even though it does give a quantified number. Yeah, so it's not like when we think of like blood alcohol content, right, where if you have a certain number, whether it's blood or, you know, in a breathalyzer, you know, they can kind of quantify, like they've kind of done, the police have done other research like, oh, like two drinks or three drinks will get you to like that point of weight. So there really isn't a lot of data out there. Because again, we can't really study that. We can't tell patients, you know, go do, you know, go use meth and then come back and we're going to test you and see how high you are, right. So that, again, continues to be a big limitation with a lot of our research. But what we can say from that is, whether it's urine or blood, depending on the need of the surgery, because where for our liability, right, if the surgeon says, hey, this is urgent or, you know, needs to go essentially, then from there, we would really just have to look at the risk calculators. Because if you're looking at the patient, and they're not acutely toxic with their presentation, and they're lower risk, then chances are you can safely, you know, still proceed to surgery, right. Again, it might make your job a little bit more difficult, pressers and whatnot. But from what the data tells us, the outcomes are good for, still good for those patients. Absolutely. Thank you. Another question from our virtual attendees, any thoughts on spinal anesthesia for a low risk person who is acutely intoxicated, but isn't showing, showing exaggerated hemodynamics? So unfortunately, our, all of our studies really only focus on general anesthesia, and there's actually not a lot of data or articles on spinal anesthesia in relation to how patients would do. So I don't think we can really safe, safely answer that question, based on what we've been reviewing. Gentlemen, very nice job, thank you for this tool, I think it's something we can all put into practice right away, so that's very nice. I am just curious though, in your review of this literature, did you run across any recommendations related to poly drug use? Because so many people will use either methamphetamine and cocaine and something else. If you did get that social history during your preoperative exam, would that change your decision making process? I mean, yeah, go ahead. Well my thoughts on that are essentially, you're really concerned about is the patient in a toxic state of mind, you know, or not state of mind, sorry, in a toxic state, symptomatology wise, you know, do they look toxic? Regardless of if they're using both meth or cocaine, our data specifically only addresses meth and cocaine, but I think from a practice, from a practice recommendation, I think it's best to look at presentation and symptomatology to determine any type of decision on if you're going to proceed with the case or not. If they look normal, and they're presenting normal vital signs, more than likely you're going to be safe to anesthetize them. Thank you gentlemen, one more question here from our virtual audience. How would you recommend implementing these tools into clinical practice? The question continues, how would you recommend getting the guidelines changed at each of our facility locations where we work? I think it would just be, you know, a slow introduction. I think, you know, smaller centers, surgery centers, or medical centers can do, you know, perhaps just some small pilot studies, and disseminate it amongst the staff, and see how it does, and just get feedback on it. I think it just has to be a very, maybe grassroots introduction of the algorithm. Yeah, so please, if any of you guys are truly interested in the algorithm, bringing it to your facility, please reach out to us, we'd be happy to work with you, share all the data and the literature that we have to support it, and hopefully we can get this thing out there and working for you guys. Perfect, last question here is, what is the next stage of your project? Yeah, so kind of along those same lines, we really hope to, you know, we're kind of at the tail end of our schooling here, about 10 months out. We would love for some of our junior classmates here to pick it up and implement it into some of our clinical sites, and start collecting data on it. And ourselves, we hope to, you know, we're looking for journals right now, we're hoping to publish. We're currently, you know, we'd love to publish with ANA, of course, but also we're looking at the perioperative nursing journal, because we think that, you know, oftentimes, or all the time, the nurse meets the patient first, right, and they often identify the substance use history before we do, and they can kind of get the ball rolling on this, because again, anybody can pick it up, read it, and follow the algorithm. And for them, it could actually be a communication tool on how they communicate with us to let us know, hey, the patient uses XYZ, you know, cocaine or meth. You know, they can also quickly calculate RCRI, they have the health history, anybody can use it, and let us know, hey, they're high risk, you know, do you think we should test them? Great. You know, we put in the order, and we kind of get that ball rolling in pre-op before we even go see the patient, because again, we might be in a different case and whatnot. That's fantastic. And thank you very much for a wonderful presentation, and thank you to our audience. Thank you.

AANA Congress

Valerie Diaz

CE credits

Jeff Darna

nurse anesthesia residents

decision algorithm

elective surgeries

cocaine or methamphetamine use

cardiac risk calculators

nurse anesthesia

substance use

risk assessments

anesthesia safety

patient safety