Anesthesia Patient Safety Podcast

#291 Managing Anesthesia Risks for Patients with Acute and Chronic Cocaine Use

• Anesthesia Patient Safety Foundation • Episode 291

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A cocaine-positive patient rolls into the OR and the monitors look fine—until twenty minutes after induction, when the blood pressure plummets. We unpack that swing from sympathetic surge to sudden crash through two real cases: an emergent trauma laparotomy complicated by asystole and a chronic intranasal user with profound hypotension that only responded to direct-acting vasopressors. From there, we connect the dots to the pharmacology that makes these events predictable and, with the right plan, manageable.

We talk candidly about what matters before wheels-in: timing of last use, objective signs of toxicity, and targeted testing. You’ll hear why urine screens can stay positive for weeks, why indirect agents like ephedrine can fail, and how phenylephrine or norepinephrine often become first-line choices. For regional anesthesia, we flag contamination risks and local anesthetic systemic toxicity concerns that call for dose adjustment and intralipid readiness. Chronic cocaine use adds another layer, including left ventricular dysfunction, myocardial infarction and fibrosis, and calcium dysregulation.

Hospital policy and equity loom large. Automatic cancellations for cocaine positive patients can worsen pain, delay care, and disproportionately impact patients with limited access. We review current evidence suggesting many asymptomatic, cocaine-positive patients tolerate elective noncardiac surgery under general anesthesia with hemodynamics comparable to controls when vigilant management is in place. The takeaway: build flexible, evidence-informed pathways that prioritize patient safety without reflexive delays, and keep a rescue mindset with careful monitoring and direct vasopressors within reach. If this sparked ideas for your practice, subscribe, share with a colleague, and leave a review so more clinicians can find these insights.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/291-managing-anesthesia-risks-for-patients-with-acute-and-chronic-cocaine-use/

© 2026, The Anesthesia Patient Safety Foundation

SPEAKER_00:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. Patients who present with acute cocaine intoxication may be at an increased risk for cardiovascular complications during anesthesia care. Anesthesia professionals need to be prepared to help keep these patients safe. This is a high-yield show because we will be reviewing the pharmacology of cocaine and its impact on safe anesthesia care. So don't turn that dial. Before we dive further into the episode today, we'd like to recognize BD, a major corporate supporter of APSF. BED has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, BD. We wouldn't be able to do all that we do without you. Our featured article today is an article between issues. It is Anesthetic Management of Patients with Cocaine Intoxication by Rahul Mishra and colleagues, published online September 29th, 2025. To follow along with us, head over to apsf.org and click on the newsletter heading. The second one down is Articles Between Issues. From there, scroll down to our featured article today. And I will include a link in the show notes as well. Let's start with some data about the use of cocaine. In 2006, there were 2.4 million Americans aged 12 years and older who were current cocaine users. In 2009, almost 500,000 emergency department visits were related to cocaine use, and many of these visits led to a required surgical procedure. There are increased risks for arrhythmias, myocardial ischemia, cerebral vasoconstriction, and stroke for patients with acute cocaine intoxication. And this means that these patients are at higher risk for complications when they present for surgery and anesthesia. Let's start with two surgical case reports of patients with recent cocaine use who required surgery and anesthesia care. Both patients consented for the publication of their respective case reports. Here is the first case report. A 28-year-old 75-kilogram man with a history of cocaine abuse presented to the emergency department with two abdominal stab wounds. On admission, he was hypertensive with a blood pressure of 181 over 85, tachycardic with a heart rate of 140 beats per minute, and awake and alert with no complaints of chest pain or shortness of breath. He received IV fluids, benzodiazepines, and opioids, but still remained tachycardic and in pain. A urine drug screen confirmed recent cocaine use, and the patient admitted to using just prior to the injury as well. Although mildly agitated, the patient remained cooperative, and he was scheduled for emergent exploratory laparotomy. On arrival to the operating room, the patient remained alert with a blood pressure of 140 over 75 and heart rate of 115 beats per minute. General anesthesia was induced with the following IV medications: midazlam, propofol, succinylcholine, and fentanyl. Maintenance included sevofluorine and 60% oxygen. The patient was initially stable, but over the next 20 minutes, his heart rate declined to the 40s before progressing to acystole. Advanced cardiac life support was started. After one round of chest compressions and a 1 milligram IV dose of epinephrine, there was return of spontaneous circulation with blood pressure 10 over 50 and a heart rate of 95 beads per minute. There were no intraabdominal or retroperitoneal injuries noted, and the abdominal cavity was closed without further cardiovascular events. Postoperatively, the patient remained intubated and was transported to the intensive care unit without vasopressor or inotropic support, followed by successful extubation, and then discharged from the hospital three days later after an uneventful recovery. No further cardiac evaluation was performed. Here is the second case report. Next, we have a 46-year-old man with a 20-year history of daily intranasal cocaine use who presented for a biopsy of a rapidly enlarging nasal lesion. Although he denied cocaine use in the two weeks prior to surgery, urine toxicology was positive. Preoperative vital signs were within normal limits, and general anesthesia was induced with propofol and fentanyl. But then, shortly after induction, the patient became profoundly hypotensive despite repeated boluses of phenylephrin and ephedrine and eventually required a phenylephrin infusion. Postooperatively, the patient remained hypotensive, and an echocardiogram revealed left ventricular hypokinesis and a reduced ejection fraction of 40 to 45%. The patient was diagnosed with cocaine-induced vasculitis and treated with steroids. He also received empiric antibiotics to treat a suspected infection. Over the next few months, the patient underwent two additional ENT procedures. During the first procedure, he was started on a phenylephrin infusion prior to induction and had no hypotensive episodes. During the second procedure, he was not treated with phenylephrin prior to induction and went on to have several episodes of interoperative hypotension that resolved after the initiation of a phenylephrin infusion. Have you taken care of a patient with acute cocaine intoxication or a history of chronic cocaine use for surgery and anesthesia care recently? Did your patient develop hypotension or cardiovascular instability? Were you prepared? Let's discuss further. For these cases, we can see that careful monitoring is required during the perioperative period, and anesthesia professionals need to be prepared to treat patients who develop cardiovascular instability. Acute cocaine intoxication leads to increases in sympathetic tone. Rapid decreases in cocaine and metabolite levels can then lead to cardiovascular collapse, which occurred in both of these cases about 20 minutes after induction. The effects of cocaine may counteract the anesthesia-induced vasodilation and also further decrease central sympathetic outflow, leading to profound hypotension and bradycardia. Keep in mind that direct-acting agents like phenolephrine or norepinephrine are more likely to be effective than indirecting vasopressors like ephedrine. It is critical that anesthesia professionals remain vigilant to anticipate cardiovascular instability from catecholamine excess or depletion to be able to intervene and resuscitate patients successfully. Anesthetic management for patients with a history of cocaine use depends on the timing of use and the patient's comorbidities. Perioperative care requires an individualized plan to prevent withdrawal. Preoperative labs and studies may include troponins, chest radiography, electrocardiogram, arterial blood gas, neuroimaging, and other studies for high-risk patients like echocardiography. For patients who present with acute cocaine intoxication, it may be challenging to determine when to proceed with surgery. What does the literature tell us? Well, one study found no increased anesthetic risk in cocaine-intoxicated patients compared to matched controls. Another survey study found that only 16% of hospitals had a formal policy for screening and treating patients who test positive for cocaine. The authors of this study suggest that when appropriate, non-emergent surgery should be delayed for at least eight hours after cocaine use and longer if necessary for patients with hemodynamic instability. Also, keep in mind that urine testing may remain positive for cocaine up to 20 days after use, which makes it difficult to use routine urine testing for risk stratification. If your anesthetic plan involves a regional anesthetic, keep in mind that cocaine may be contaminated with other local anesthetics. Patients may then be at risk for local anesthetic toxicity, especially with high-dose regional techniques. A dose adjustment may be necessary. Another important consideration is keeping patients with chronic cocaine use safe during anesthesia care. Be on the lookout for left ventricular dysfunction. Patients are also at risk for myocardial infarction, fibrosis, catecholamine excess, and calcium dysregulation. There are animal studies that have shown that prolonged cocaine use may lead to myocardial enzyme depletion and impaired cardiac function. Keeping patients with acute and chronic cocaine intoxication likely requires comprehensive screening when the results could impact anesthetic management or surgical timing. And standardized protocols need to focus on individualized care and preparation to treat hemodynamic instability. Before we wrap up for today, we are going to dive right back into the literature and the 2022 anesthesia and analgesia article, Cocaine Positive Patients Undergoing Elective Surgery, from avoiding case cancellations to treating substance use disorders. I will include the citation in the show notes as well, and we hope that you will check out the entire article. The authors write about the challenges that anesthesia professionals face when patients have a positive urine toxicology test result. Do you need to postpone elective surgery or go ahead and proceed with the anesthetic in surgery? Postponing elective surgery has additional consequences, including prolonged patient suffering, worse patient experiences, and treatment delays with worse clinical outcomes. In addition, there is a higher prevalence of substance use disorder in socioeconomically disadvantaged populations who have limited access to care, which is another consequence for delaying surgery in these situations. It may be safe to proceed with surgery even for patients with a preoperative cocaine-positive urine toxicology result. A 2022 single-center prospective cohort study by Moon and colleagues looked at asymptomatic patients with a history of cocaine use and a positive preoperative urine test and intraoperative hemodynamic events. The patients received general anesthesia for elective non-cardiac surgery and had similar rates of interoperative hemodynamic events compared to 154 cocaine-negative patients. Check out the show notes for the citation to the study for more information. Going forward, additional research is needed to evaluate the effects of chronic cocaine use and further guide anesthesia professionals. If you have any questions or comments from today's show, please email us at podcast atapsf.org. 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. We are excited to announce the 2026 APSF Trainee Quality Improvement Patient Safety Recognition Program. This program hosts tracks for physician anesthesiology residents, nurse anesthesia students, and student anesthesiology assistants. Eligible participants include current trainees and those who graduated in the immediately prior academic year. This is your chance to demonstrate your program's work in patient safety and QI initiatives. The winner in each track will be notified around August 1st, 2026, and the APSF will sponsor the winners to attend the 2026 Stolting Conference in National Harbor, Maryland to share your work and network with attendees. Here's how to submit your work. You may independently determine the best media for submitting your project summary. Acceptable formats include a document or an audio or video recording. The submission deadline is June 1, 2026, so you have some time to get organized and excited to submit your best work and support the APSF vision. Check out the show notes for more information about the submission process. You can also email traineeqi at apf.org with any questions. That's it for today's episode. If this conversation sparked a thought or gave you something to take back to your practice, make sure you're subscribed so you don't miss future episodes. You can listen wherever you get your podcasts, and sharing the show with a colleague really helps spread the word about improving patient safety in anesthesia. Thanks for listening. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.