Stopping Smoking Improves Recovery

1. Stopping Smoking Improves Recovery Anil Gupta Department of Anesthesiology Örebro

2. Smoking Deaths About 20% of all deaths are attributable to Tobacco Peto et al. Lancet 1992

3. Smoking in Sweden • Percentage of daily smokers among adults (Age 16-84) 2004 – USA – 23% smokers

4. Types of Smokers Non-smokers Current smokers/Passive smokers Ex-smokers

5. Tobacco smoke • > 3000 chemicals • gaseous - 80 – 90% (Nitrogen, O2, CO2) • particulate - nicotine • Harmful substances • Nicotine • CO • Oxidant gases • Polycyclic hydrocarbons

6. Risks of Smoking • Smoking is a known Risk factor for: • Lung cancer • Bladder cancer • Chronic obstructive pulmonary disease • Emphysema • Hypertension • Coronary artery disease • Peripheral vascular disease • Ulcers • Asthma

7. Pre-existing medical conditions as predictors of adverse events in day surgery • 17 638 patients studied, 14% were smokers • Smoking was associated with a higher risk of respiratory complications (OR: 3.84) • Excessive pain was found in 7.4% of smokers • Cardiovascular complications were found in 2.4% smokers Chung et al. BJA 1999

8. Smoking and the Cardiovascular system Effects of Nicotine • Increase in BP • Increase in HR • Increase in SVR Due to the release of catecholamines from adrenal meddula 30 min after smoking Also increases coronary artery vascular resistance Myocardial oxygen supply-demand imbalance Myocardial ischemia

9. Smoking and the Cardiovascular system Effcts of Carbon monoxide (CO) • Increase in COHb levels lead to a decrease in oxygen content • Shift of the oxygen dissociation curve to the left • Weak, direct negative ionotropic effect on the heart Myocardial oxygen supply-demand imbalance Myocardial ischemia

10. Harmful effects of ’Recent smoking’ Cardiovascular Complications • Increased myocardial work • Decreased oxygen supply • Coronary vasocontriction • Increased catecholamine release Increased concentrations of CO has been correlated to frequency of ST-depression during general anaesthesia

11. Effect of 12 h ’smoking fast’ on COHb* • CO* – half life of 4-6 h at rest • (depends on ventilation) • 12 h ’smoking fast’ removes about 87% of CO * COHb = Carboxyhemoglobin * CO = Carbon monoxide

12. Pulse oximetry and smoking Egan and Wong JCA 1992

13. Smoking and the Respiratory system • Irritants in smoke lead to: • Increase in mucous secretion (2 - 6 weeks) • Increase in viscosity of mucous • Decrease in ciliary activity (4 - 6 days) • Small airway narrowing (4 weeks – 6 months) • Decrease in surfactant Return to normal Impaired tracheobronchial clearence of secretions (3 months) Chronic bronchitis

14. Smoking and the Hemostatic system • Smoking: • Increases Hb • Increases Red blood cells • Increases White blood cells • Increases Platelets and their reactivity Increased hematocrit and blood viscocity Increased risk of thrombotic diseases (NOT deep vein thrombosis)

15. Smoking and Perioperative Complications • Chest complications • Atelectases • Pneumonia • Wound complications • Delayed healing • Cardiovascular complications • Myocardial ischemia

16. Perioperative Problems • Drug metabolism • Smoking causes induction of liver enzymes • Benozidiazepine requirements may be greater • Not a pharmacokinetic effect • Neuromuscular drugs • Smoking (nicotine) stimulates ACh receptors • Effects of N-M blockers vary depending on the drug • Pain and analgesic drugs • Decreased tolerance to pain; more analgesics • Fentanyl is metabolized quickly; not paracetamol

17. What is the Evidence that Smoking causes harm? 1. Wound healing

18. Compared to Non-smokers: A higher risk for wound infection (OR: 16.3) Myles et al. Anesthesiology 2002

19. Conclusion: ” …… extreme discretion should be exercised when offering abdominoplasty procedures to smokers ……..”

20. Wound Healing and Infection • Reasons • Nicotine • Causes cutaneous vasoconstriction, decreasing blood supply to tissues • Decreases proliferation of red blood cells, fibroblasts and macrophages • Increase in platelet aggregation • Carbon monoxide (CO) • Decrease in oxygen delivery to tissues • Shift of O2 dissociation curve to the left • Inhibition of enzyme system by hydrogen cyanide Silverstein P. Am J Med 1992

21. What is the Evidence that Smoking causes harm? 2. Respiratory complications

23. Compared to Non-smokers: A higher risk for coughing, laryngospasm and all respiratory complications Myles et al. Anesthesiology 2002

24. Respiratory Complications and smoking • Reasons: • Increase in mucous production, which is thick • Ciliary dysfunction with difficulty in removal of mucous • Increase in pulmonary epithelial permeability leading to increased reactivity • Small airway narrowing

25. Smoking and Respiratory Complications - Children • Passive smoking Cotinine is a major metabolite of nicotine and can be detected in the urine (even during passive smoking, as in children) Nicotine and cotinine levels in the urine are consistently higher in children exposed to environmental smoke Conclusion Children exposed to passive smoking had a higher incidence of respiratory events in the recovery room

26. What is the Evidence that Smoking causes harm? 3. Other complications

27. Methods: 649 patients underwent hernia repair (open suture or open mesh) 544 evaluated for recurrence after 2 yrs Results:Smoking associated significantly and independently with recurrence compared to non-smoking (OR: 2.2). Open sutured repair compared to mesh repair was the most significant predictor for recurrence (OR: 7.23). Local anesthesia was associated with a higher recurrence rate compared to general anesthesia! Conclusion:

28. Conclusion: A higher incidence of nausea (but not vomiting) was found in non-smokers compared to smokers. Anaesthesia 2000

29. What is the Evidence that Smoking causes harm? Conclusions • Smoking increases the risk for: • Wound complications • Respiratory complications • Probably ischemia • Smoking decreases the risk for: • Nausea (but not vomiting)

30. Does stopping smoking preoperatively reduce perioperative complications?

31. (Orthopedic surgery)

32. Retrospective study !

33. 4 h after induction of anesthesia: *Decrease in antimicrobial function of alveolar macrophages were 1.5 - 3 times greater in current and former smokers *Increase in expression of cytokines was 2-5 times less in smokers and former smokers

34. Anesthesia related Complications • Increase in secretions (1-2 weeks) • Laryngospasm • False SpO2 readings on pulse oximeter (COHb) • Tachycardia/Hypertension/ST-T • changes (recent smoking)

35. Does stopping smokingpreoperatively reduce perioperative complications? • Conclusions • Reduction in wound-related complications • Reduction in respiratory complications • Reduction in anesthesia-related complications • Reduction in recurrence of hernias

36. Consequences of stopping smoking

37. Problems • Increased cough and sputum production • Never reported to increase chest complications • Can be managed by drugs perioperatively • Nictonine withdrawl results in increased stress • No increase in psychological stress reported in smokers vs. non-smokers (Warner, Anesthesiology 2004) • Effects of nicotine withdrawl are not consistent • If they occur, they can be managed using NRT Warner DO, A&A 2005

38. Advise on Stopping Smoking • 66% physicians do not advise their patients to stop smoking • 56% patients report that they have never been told to stop smoking by a physician • 80% of units in UK had written advise to patients to stop smoking before surgery • 25% advised stopping smoking 12 h before • 25% advised stopping smoking 1 week before • 50% advised stop smoking 1-6 weeks before

39. Helping patients quit smoking is Teamwork (it is never someone else’s problem!) Anesth Analg. 2005 Aug;101(2):481-7,

40. Proven Methods to help Smokers Quit

41. Anesthesiologists • Ask about tobacco use • Advise to quit • Assess willingness to quit • Assist in quitting • Arrange follow-up

42. Written instructions to Quit Smoking Warner 2005

45. When should one stop smoking? Conclusions Miller RD, Anesthesia 2005

46. Can these recommendations be followed (in practice)? • For elective surgery • Stop smoking 6-8 weeks before planned surgery by surgeons, nurses and councellors • Stop smoking 12 h before planned surgery by Anaesthesiologists • For cancer surgery (semi-acute) • Advise to stop smoking as soon as Surgeon plans the operation (depends on waiting times) • Certainly, in all patients, the no smoking rule should apply for 12 h before anaesthesia

47. Final Conclusions • Smoking increases the risk for: • Wound infections • Respiratory events • Stopping smoking improves outcome • Reduction in wound-related complications • Reduction in respiratory complications Optimal time to stop smoking is > 6 – 8 weeks before planned surgery

48. Final Conclusions • Physicians should play an active role in informing patients to stop smoking • Information of the risks and consequences of smoking should be incorporated into the preoperativenursing work-up • Councelling through professionals should be an integral part of the operating facility

49. Stopping Smoking Improves Outcome Thank you!