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Successful elective surgery in a patient with a positive preoperative cocaine toxicology screen.

Dear Editor:

We read with interest the case report from the EAR, NOSE, & THROAT JOURNAL entitled "Successful elective surgery in a patient with a positive preoperative cocaine toxicology screen" by Drs. Witt and Wilson concerning positive preoperative cocaine drug screening. (1) In the anesthesiology literature, the latest review of patients with a positive cocaine screen confirms that in the absence of cocaine intoxication, it is reasonable to proceed with elective procedures. (2) However, we wish to expand on the term carefully selected used by Drs. Witt and Wilson.

In the Witt and Wilson case report, the patient's medical history, specifically cardiac, and the patient's American Society of Anesthesiology physical status (ASA status) are not clear. Chronic cocaine abusers are at an increased risk of cardiac events, especially coronary ischemia and ventricular dysrhythmias, in the perianesthetic period. In fact, cocaine abusers are at significant risk of lethal dysrhythmias if their electrocardiogram shows a QTc interval of 500 milliseconds or more. The study we cite from the British Journal of Anaesthesia (2) only looked at ASA I and II patients. Those with ASA status of III or higher may incur greater risk.

While the presence of cocaine metabolites in a drug screen is in itself no indication to cancel an elective procedure, other chronic findings should warrant further investigation. Careful history and physical exam, including preoperative ECG, looking for QT interval prolongation or evidence of ischemia, should be an integral part of the preoperative assessment. Careful coordination and cooperation between services in the preoperative period is needed to ensure proper screening of these patients.

References

(1.) Witt RL, Wilson P. Successful elective surgery in a patient with a positive preoperative cocaine toxicology screen. Ear Nose Throat J 2010;89(2):E14-16.

(2.) Hill GE, Ogunnaike Bo, Johnson ER. General anaesthesia for the cocaine abusing patient. Is it safe? Br J Anaesth 2006;97(5):654-7.

Gregory L. Rose, MD

Assistant Professor

I. Thomas McLarney, MD

Assistant Professor

F.C. Massa, MD

Assistant Professor

Department of Anesthesiology

University of Kentucky College of Medicine

Lexington

Response:

We appreciate the comments of Dr. Rose, Dr. McLarney, and Dr. Massa regarding our article. They have posed questions regarding the patient's medical history and wish to expand our use of the term carefully selected to include only those patients with an American Society of Anesthesiology (ASA) risk of I or II and, specifically, no QT interval prolongation on EKG.

The patient in our case report had no other medical problems (specifically no cardiac history), a normal EKG, and was an ASA risk I. Our article states, "Our institution has concluded that elective head and neck surgery may be safely performed in carefully selected, hemodynamically stable patients who have tested positive for cocaine ingestion provided that they have been closely observed for 8 hours preoperatively and that they have provided informed consent. Outcome studies are needed."

Our article further states, "Preoperative precautions include electrocardiography, blood chemistries, and a careful assessment of blood pressure, respiratory rate, and pulse. Intraoperative drug management with a beta blocker is made readily available to the anesthesia staff."

Based on our published comments, we concur with the remarks of Drs. Rose, McLarney, and Massa and are pleased with their interest in our work.

Robert L. Witt, MD, FACS

Chief, Head and Neck Oncology

Helen F. Graham Cancer Center

Christiana Care Health Systems

Newark, Delaware
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Author:Rose, Gregory L.; McLarney, J. Thomas; Massa, F.C.
Publication:Ear, Nose and Throat Journal
Article Type:Letter to the editor
Geographic Code:1USA
Date:Jun 1, 2010
Words:560
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