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French Conference of Experts Peri-operative smoking control

French Conference of Experts Peri-operative smoking control. Background. Smoking consumption is the cause of a significant increase risk of surgical adverse events, too often neglected.

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French Conference of Experts Peri-operative smoking control

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  1. French Conference of Experts Peri-operative smoking control

  2. Background • Smoking consumption is the cause of a significant increase risk of surgical adverse events, too often neglected. • A good assumption of the responsibility of the tobacco smoke must lead to a quick benefit, reducing general and local surgical complication rate, which would constitute a significant profit in term of health and savings.

  3. Gradation A, B, C, D or E of recommendations Most of the recommandations are grade E Recommandations level A are only 3%

  4. 6 questions QS1: What are the tobacco related risks in surgical period? QS2 What are the proven benefits from of quitting smoking during the surgical period? QS3 How a smoker should be help before elective surgery? QS4-What is the role of each health professionals in the surgical period? Qs5- What are the specificities of an anesthesia for a smoker patient ? QS 6: How to deal with dependent smoker hospitalized for a not anticipate surgical procedure?

  5. Number of smokers amongsurgical patients in France Daily smokers 13 millions General ansethesia 8 millions Smokers With surgery 2 millions

  6. Moller study : risk of ICU transfer after surgery • Prospective study on 6 026 patients • General surgery and orthopedic surgery • compare NS et S > 50 Py to ES or S< 50 Py or NS • Admission in ICU : significantly higher if patient had smoke > 50 Py (p<0.001). Mortality : Non significant excess of mortality after smoker admitted in ICU compare to non smoker 37% vs 24% (OR=2.02 ; 99CI = 0.92-4.41 ; p=0.08) Moller AM, Pedersen T, Villebro N, Schnaberich A, Haas M, Tonnesen R. A study of the impact of long-term tobacco smoking on postoperative intensive care admission. Anaesthesia. 2003 Jan;58(1):55-9.

  7. General surgery mortality study Delgado-Rodriguez • Prospective study • 2 989 surgical patients • Increase admission in ICU if ≥ 51 Py (OR=2.86 ; 95 CI = 1.21-6.77). • Increase death at hospital if ≥ 51 Py (OR=2.56 ; 95 CI = 1.10-5.97). Delgado-Rodriguez M, Medina-Cuadros M, Martinez-Gallego G, Gomez-Ortega A, Mariscal-Ortiz M, Palma-Perez S, Sillero-Arenas M. A prospective study of tobacco smoking as a predictor of complications in general surgery.Infect Control Hosp Epidemiol. 2003 Jan;24(1):37-43

  8. Myles study on 489 surgical patients • Prospective study • CO measurement to confirm smoking status reported • Record of all respiratory complications. • Respiratory complications OR= 1.71; 95% IC, 1.03-2.84; p= 0.038 Myles PS, Iacono GA, Hunt JO, Fletcher H, Morris J, McIlroy D, Fritschi L. Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology. 2002 Oct;97(4):842-7.

  9. Schwilk study 26 961 surgical patients • Prospective study 26 961 patients (7122 =26.4% smokers) • COPD 23.3% (4.8% among smokers). • 1573 complications in 1397 patients (5.2%) • 1114 respiratory events • RR of respiratory events • 1.8 in smokers • 2.3 in smokers 16-39 y old) • 6.3 in overweight young smokers • RR of bronchospasm : 25.7 in young smokers with COPD Schwilk B, Bothner U, Schraag S, Georgieff M. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiol Scand. 1997 Mar;41(3):348-55.

  10. Moller randomized study cardiovascular complications • 120 smokers randomized 6-8 weeks before surgery • Nurse training every week + medications as need • No specific intervention (p=0.08) Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

  11. Moller randomized study all complications • 120 smokers randomized 6-8 weeks before surgery • Nurse training every week + medications as need • No specific intervention (p=0,0003) Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

  12. 1.3 Which are the risks of general complications (cardiovascular, respiratory, and infectious,…)? • The increase in the relative risk (RR) according to studies concerns: • The risk of being transferred to an intensive care units (RR from 2.02 to 2.86) [D], • Infectious complications (RR from 2 to 3.5) [D], • Coronary complications (RR of 3) [D], • Immediate respiratory complications (RR of 1.71) [D].

  13. Sorensen prospective study scar in healthy voluntaries • 48 smokers 30 non smokers randomized. • Incisions in sacrum area (n= 228) • Smoke 20 cig / j 1 week then  continue to smoke •  Patch placebo •  patch active NB: No difference between non smokers (patch or placebo ) no influence of nicotine. P <0.05 Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003 Jul;238(1):1-5.

  14. Möller : Prospective randomized study on scar complications • 120 smokers randomized 6-8 weeks before surgery • Nurse training every week + medications as need • No specific intervention (p=0.001) Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

  15. Möller prospective randomized studyneed for second intervention • 120 smokers randomized 6-8 weeks before surgery • Nurse training every week + medications as need • No specific intervention (p=0.07) Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

  16. Retrospective Padubidri study on 748 breast reconstructions Necrosis of mastectomy scrapsmokers 7,7 % • Ex smokers 2,6 % • Non smokers 1,5 % (p < 0.001) Padubidri AN, Yetman R, Browne E, Lucas A, Papay F, Larive B, Zins J. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg. 2001 Feb;107(2):342-9.

  17. Retrospective Möller study811 hip or knee prosthesis 232 smokers (28.6%) and 579 non-smokers  Smoking doubled the risk of prolonged hospitalization (> 15 days) Complication of scar • smokers RR 3.2 Admission in ICU • Smokers RR 8.5 Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003 Mar;85(2):178-81.

  18. Willigendael Meta-analysis on vascular by-pass. • 29 studies (4 randomized, 12 prospective and 13 retrospectives). In randomized trial and prospective studies, the risk of by pass failureincrease 3.09 (IC: 2.34-4.8 p< 0.0001) with smoking continuation. No difference between venous and polyester by pass. Correlation between by pass permeability and intensity of tobacco consumption . Quitting at surgery provide a permeability rate close to non smoker rate. Continuation of smoking could be responsible of 57% of failure (IC 95%, 50%-64%). Willigendael EM, Teijink JA, Bartelink ML, Peters RJ, Buller HR, Prins MH. Smoking and the patency of lower extremity bypass grafts: a meta-analysis. J Vasc Surg. 2005 Jul;42(1):67-74.

  19. Willigendael meta-analysis on vascular by pass Prospective Studies Retrospective studies Willigendael EM, Teijink JA, Bartelink ML, Peters RJ, Buller HR, Prins MH. Smoking and the patency of lower extremity bypass grafts: a meta-analysis. J Vasc Surg. 2005 Jul;42(1):67-74.

  20. Prospective randomized Mollerstudy : days in hospital • 120 smokers randomized 6-8 weeks before surgery • Nurse training every week + medications as need • No specific intervention (p < 0.01) 8-65 jours 7-55 jours Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

  21. medico-economic outcome • If 10% of surgical patients benefit of the same outcome than in Möller study, the treatment of 200 000 smoker during preoperative period will save : 68 000 surgical complications (+ 34% of patients) 18 000 second intervention (+ 9% of patients) 400 000 days in hospital (+ 2 days per patient) 109 000 days un ICU(+ 0,545 day per patient)

  22. QS 2 QS2 What are the proven benefits from of quitting smoking during the surgical period?

  23. 2.1 What are the benefits of quitting smoking according to the period before the surgical procedure (> 48 hours)? • The surgical risk of former smokers for a long period is lower than the risk of current smokers and not different from those of non smokers [C]. • Smoking cessation of 6-8 weeks before surgery diminishes the surgical risk observed in current smokers [A]. • Smoking cessation closer to surgery, 3-4 weeks before, is beneficial for decreasing all the surgical risks [C]. • Smoking cessation of less than 3 weeks before surgery is beneficial, as it reduces the local surgical site’s complications that counterbalance the potential increase risk of respiratory complications [E].

  24. 2.2 What are the benefits of smoking reduction with or without nicotine replacement therapy before surgical procedure, according to the period (> 48 hours)? • Smoking reduction without nicotine replacement therapy is not to be recommended. [E]. • One may anticipate a potential benefit of an observed decrease in the circulating CO, observed when smoking reduction is associated with nicotine replacement therapy [E]. • There is a lack of evaluation of the smoking reduction under nicotinic replacement therapy during the surgical period [E].

  25. 2.1 Benefits to quit tobacco according to the delay before?

  26. 2.3 What are the benefits of late smoking cessation, with or without nicotine replacement therapy, in the 48 hours preceding a surgical procedure • From the physiological point of view, complete smoking cessation even of less than 48 hours before surgical procedure should be beneficial [E]. • Temporary increase in cough and bronchial secretions are the only related adverse events that can be harmful just after smoking cessation [E].

  27. Rapid decrease of CO after smoking cessation

  28. Decrease of cardiac and respiratory risk in the 48 hours of quitting Sputum production increase initially Cardiac risk decrease the day of quiting Yamashita S, Yamaguchi H, Sakaguchi M, Yamamoto S, Aoki K, Shiga Y, Hisajima Y. Effect of smoking on intraoperative sputum and postoperative pulmonary complication in minor surgical patients. Respir Med. 2004 Aug;98(8):760-6.

  29. 2.5 Does smoking cessation during the surgical period contribute to long term smoking cessation? • In the general population, the relapse rate after quitting is approximately 50% one year after cessation [A]. • In the case of cardiac surgery, 50% of post coronary artery surgical patients who quit smoking had relapsed one year later [C]. • Quitting smoking for a surgical procedure is a positive prognostic factor for long term smoking abstinence. However, the high relapse rate highlights the need to reinforce the prevention of relapses [E]

  30. Ratner study : 237 smokers randomized for smoking cessation before elective surgery Ratner PA, Johnson JL, Richardson CG, Bottorff JL, Moffat B, Mackay M, et al .Efficacy of a smoking-cessation intervention for elective-surgical patients. Res Nurs Health 2004; 27:148-61.

  31. 2.6 What are the benefits of continuous abstinence after surgery on bone consolidation and thrombosis risk? • When smoking abstinence is continued in the postoperative period, the benefit on bone consolidation is demonstrated [D] and the benefit on skin and soft cicatrisation is probably beneficial [E]. • When smoking cessation is maintained in the post operative period, benefits are seen in osseous consolidation [D], and probably in skin and soft cicatrisation [E]. • The permeability of vascular bypass is improved, when smoking cessation is prolonged during the post operative period [A]. • In smokers, thromboses of vascular bypass are 57% tobacco related [B].

  32. QS 3 QS3 How a smoker should be looked after before elective surgery?

  33. Standard procedure for identification and treatment of smoker before surgery Accéder à la procédure en Word ou pdf

  34. Procedure for in patients Accéder à la procédure en Word ou pdf

  35. Conclusion • All surgical department has to be organized to identified smokers 6-8 weeks before surgery as soon as possible • All surgical department has to organize smoking cessation in preoperative period with adequate tools • All surgical department need to organize substitution of smoker during surgery • All surgical department had to organize follow up of formers smoker to prevent relapse

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