Drug-laced vaping-implications and emerging perioperative challenges for the anesthesiologist: a narrative review

Drug-laced vaping (DLV) involves vaping devices used to inhale non-nicotine psychoactive substances (e.g., cannabinoids, stimulants, opioids, benzodiazepines [BZDs]), sometimes without the user's awareness. Because exposure is often undisclosed and may not be detected by routine toxicology screening, DLV poses a hidden perioperative risk. We aimed to summarize current evidence, highlight emerging challenges, and outline implications for anesthesiologists.

We performed a structured narrative review of MEDLINE, Embase®, Scopus, and the Web of Science™ (inception to November 2025), supplemented by public health alerts, forensic/toxicology reports, and drug-checking data.

Reported perioperative-relevant presentations cluster into 1) airway and lung injury (airway irritation/hyperreactivity; e-cigarette- or vaping-associated lung injury), 2) autonomic and cardiovascular instability (including stimulant-associated hypertension and dysrhythmias), and 3) altered consciousness and ventilatory compromise (notably opioid- or BZD-associated sedation and respiratory depression), with additional concern for adrenal suppression after chronic exposure to etomidate-laced products. Emerging agents (e.g., synthetic cannabinoids and designer BZDs) may evade routine immunoassays, while confirmatory testing (e.g., mass spectrometry) is often unavailable or too slow for urgent care. We therefore propose a pragmatic perioperative approach emphasizing targeted history, syndromic assessment, and structured escalation planning.

Drug-laced vaping is an emerging, underrecognized perioperative challenge with limited direct perioperative evidence; many recommendations require extrapolation from toxicology and expert consensus. We provide pragmatic checklists for preoperative assessment, intraoperative monitoring, and postoperative disposition for patients with history or suspected history of DLV.