Anesthetic Management of Cocaine Users

Preoperative Assessment and Risk Stratification

The American Heart Association recommends that patients with recent cocaine use proceed with general anesthesia if they are clinically non-toxic, but avoid beta-blockers in those showing signs of acute intoxication due to risk of unopposed alpha-adrenergic stimulation causing fatal coronary vasospasm 1, 2, 3
Most cocaine-associated myocardial infarctions occur within 3 hours of use, with a 24-fold increased MI risk in the first hour, according to the American College of Cardiology 4
Cocaine metabolites persist up to 24 hours and can cause delayed coronary vasoconstriction, with symptoms potentially occurring 18 hours after use, as reported by the American Heart Association 4
Urine testing for benzoylecgonine is the most reliable method to detect recent use, as self-reporting significantly underestimates exposure, according to the American College of Cardiology 4, 5

Signs of acute intoxication include euphoria 2, tachycardia 6, hypertension 7, hyperthermia 7, and agitation 7, as identified by the American Society of Anesthesiologists
Clinically non-toxic patients have normal blood pressure and heart rate, are normothermic, have a normal or unchanged ECG, a QTc interval <500ms, and positive urine cocaine metabolites alone without clinical signs, as defined by the American College of Cardiology 7

The American Heart Association recommends evaluating for cocaine-related cardiac pathologies preoperatively, including accelerated atherosclerosis, myocarditis, cardiomyopathy, aortic dissection, coronary artery dissection, and pulmonary hypertension 6, 3

The American College of Cardiology recommends using benzodiazepines and nitroglycerin as first-line agents for hypertension and tachycardia in acute intoxication 1, 2, 3
Beta-blockers should be avoided in acute intoxication due to the risk of unopposed alpha-adrenergic stimulation causing severe coronary vasospasm, as warned by the American Heart Association 1, 2
The American Society of Anesthesiologists recommends using direct-acting vasopressors, such as phenylephrine or noradrenaline, in chronic users with catecholamine depletion 7

The American College of Cardiology recommends monitoring for arrhythmias, including ventricular tachycardia, supraventricular tachycardia, and bradyarrhythmias, as 90% of complications occur within the first 12 hours after presentation 4
Serial vital sign assessment is crucial in patients with cardiovascular complications, as emphasized by the American Heart Association 3
In-hospital mortality for cocaine-associated MI is low when appropriately managed, according to the American College of Cardiology 4