Learning objectives

• Describe the perioperative complications associated with smoking
• Manage smoking patients scheduled for anesthesia

Background

• Cigarette smoking is one of the primary causes of preventable illness and premature death
• Quitting smoking before surgery leads to a reduced incidence of postoperative complications
• The longer the period of cessation before surgery, the greater the benefit

Perioperative complications associated with smoking

• There is a clear dose-response relationship between the amount smoked and perioperative morbidity
• Possible complications:

Management

• Education regarding the benefits of pre-operative smoking cessation when possible
• Ideally, smoking is stopped 8 weeks before surgery
• Stop smoking 24h before surgery to negate the effects of nicotine and COHb
• Effects of smoking cessation:
  • Symptoms of cough and wheeze decrease within weeks
  • Mucociliary clearance starts to improve after a week 
  • Lung inflammation takes much longer to subside
  • Goblet cell hyperplasia regresses and alveolar macrophages decrease
  • Decrease in all-cause mortality in patients with coronary artery disease by approximately 33%
  • Risk of coronary heart disease and cerebrovascular disease approaches the risk of never-smokers within 10-15 years
• Guidance
  • Patients who smoke are more likely to quit if they are offered a combination of interventions
  • Ask and record smoking history (pack-years)
  • Advise that the most effective way to quit is with a combination of medication and specialist support
• Pharmacological aid
  • Nicotine replacement therapy (patches, lozenges, chewing gum, or nasal sprays.)
  • Oral bupropion 
  • Oral varenicline

Suggested reading

• Carrick MA, Robson JM, Thomas C. Smoking and anaesthesia. BJA Educ. 2019;19(1):1-6.

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