The patient with obesity and super-super obesity: Perioperative anesthetic considerations.

Obesity is associated with increased morbidity and mortality related to many complex physiologic changes and the rise worldwide has had far ranging implications in healthcare. According to the World Health Organization, over 2.8 million people die each year from being overweight or obese. Patients who are obese often need surgical procedures or interventional pain procedures and are at higher risk of complications. Patients with super-super obesity are those with body mass index greater than 60 kg/m2 and are at even greater risk for complications. The present investigation reviews epidemiology, pathophysiology, and anesthesia considerations for best practice strategies in managing these higher risk patients. Clinical anesthesiologists must utilize careful assessment and consultation in developing safe anesthesia plans. Improvements in technology have advanced safety with regard to airway management with advanced airway devices and in regional anesthesia with ultrasound-guided nerve blocks that can provide increased flexibility in formulating a safe anesthetic plan. As well, newer drugs and monitors have been developed for perioperative use to enhance safety in patients with obesity.

Alternative Options for Complex, Recurrent Pain States Using Cannabinoids, Psilocybin, and Ketamine: A Narrative Review of Clinical Evidence.

With emerging information about the potential for morbidity and reduced life expectancy with long-term use of opioids, it is logical to evaluate nonopioid analgesic treatments to manage pain states. Combinations of drugs can provide additive and/or synergistic effects that can benefit the management of pain states. In this regard, tetrahydrocannabinol (THC) and cannabidiol (CBD) modulate nociceptive signals and have been studied for chronic pain treatment. Psilocybin, commonly known as "magic mushrooms", works at the serotonin receptor, 5-HT2A. Psilocybin has been found in current studies to help with migraines since it has a tryptamine structure and works similarly to triptans. Psilocybin also has the potential for use in chronic pain treatment. However, the studies that have looked at alternative plant-based medications such as THC, CBD, and psilocybin have been small in terms of their sample size and may not consider the demographic or genetic differences in the population because of their small sample sizes. At present, it is unclear whether the effects reported in these studies translate to the general population or even are significant. In summary, additional studies are warranted to evaluate chronic pain management with alternative and combinations of medications in the treatment of chronic pain.

The effects of concurrent administration of cytochrome P-450 inhibitors on the pharmacokinetics of oral methadone in healthy dogs.

OBJECTIVE: The objective was to examine the effects of inhibiting cytochrome P450 (CYP) on the pharmacokinetics of oral methadone in dogs. STUDY DESIGN: Prospective non-randomized experimental trial. ANIMALS: Six healthy Greyhounds (three male and three female). METHODS: The study was divided into two phases. Oral methadone (mean = 2.1 mg kg(-1) PO) was administered as whole tablets in Phase 1. In Phase 2 oral methadone (2.1 mg kg(-1) PO) was administered concurrently with ketoconazole (13.0 mg kg(-1) PO q 24 hours), chloramphenicol (48.7 mg kg(-1) PO q 12 hours), fluoxetine (1.3 mg kg(-1) PO q 24 hours), and trimethoprim (6.5 mg kg(-1) PO q 24 hours). Blood was obtained for analysis of methadone plasma concentrations by liquid chromatography with mass spectrometry. The maximum plasma concentration (C(max)), time to C(max) (T(max)), and the area under the curve from time 0 to the last measurable time point above the limit of quantification of the analytical assay (AUC(0-LAST)) were compared statistically. RESULTS: The C(max) of methadone was significantly different (p=0.016) for Phase 1 (5.5 ng mL(-1)) and Phase 2 (171.9 ng mL(-1)). The AUC(0-LAST) was also significantly different (p=0.004) for Phase 1 (13.1 hour ng mL(-1)) and Phase 2 (3075.2 hour ng mL(-1)). CONCLUSION AND CLINICAL RELEVANCE: Concurrent administration of CYP inhibitors with methadone significantly increased the area under the curve and plasma concentrations of methadone after oral administration to dogs. Further studies are needed assessing more clinically relevant combinations of methadone and CYP inhibitors.