Tobacco control for anesthesiologists

Smoking Cessation for Preoperative Optimization

Cigarette smoking is associated with pulmonary and cardiovascular disease and confers increased postoperative morbidity and mortality. Smoking cessation in the weeks before surgery can mitigate these risks, and surgeons should screen patients for smoking before a scheduled operation so that appropriate smoking cessation education and resources can be given. Interventions that combine nicotine replacement therapy, pharmacotherapy, and counseling are effective to achieve durable smoking cessation. When trying to stop smoking in the preoperative period, surgical patients experience much higher than average cessation rates compared with the general population, indicating that the time around surgery is ripe for motivating and sustaining behavior change. This chapter summarizes the impact of smoking on postoperative outcomes in abdominal and colorectal surgery, the benefits of smoking cessation, and the impact of interventions aimed to reduce smoking before surgery.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

Surgical smoke and the anesthesia provider

Surgical smoke generated by use of electrosurgical units (ESUs), lasers, and ultrasonic scalpels constitutes a physical, chemical, and biological hazard for anesthesia personnel. Inhalation of particulate matter with inflammatory consequences, pulmonary injury from products of tissue pyrolysis, exposure to mutagens and carcinogens, and the transmission of human papillomavirus (HPV) and possibly other pathogens represent a spectrum of adverse effects associated with the occupational exposure to surgical plume. While adequate operating room ventilation and use of high filtration-efficiency masks offer some protection from these conditions, the most effective method of safeguarding against surgical smoke involves its removal with a dedicated smoke evacuation device (SED). Despite the fact that many professional and governmental agencies have endorsed widespread usage of SEDs, anesthesia providers have been largely silent on this subject, with few reports within the field of anesthesiology and perioperative medicine regarding these hazards. SED use is relatively infrequent in most surgeries, and this condition reflects surgeons' reluctance to employ these devices, likely resulting from lack of education and less than optimal technology. Anesthesia societies and academic centers can serve critical roles in advocating employment of SEDs in much the same way that they have supported perioperative smoking cessation.

Awake craniotomy: improving the patient's experience

PURPOSE OF REVIEW

Awake craniotomy patients are exposed to various stressful stimuli while their attention and vigilance is important for the success of the surgery. We describe several recent findings on the perception of awake craniotomy patients and address nonpharmacological perioperative factors that enhance the experience of awake craniotomy patients. These factors could also be applicable to other surgical patients.

RECENT FINDINGS

Proper preoperative counseling gives higher patient satisfaction and should be individually tailored to the patient. Furthermore, there is a substantial proportion of patients who have significant pain or fear during an awake craniotomy procedure. There is a possibility that this could induce post-traumatic stress disorder or related symptoms.

SUMMARY

Preoperative preparation is of utmost importance in awake craniotomy patients, and a solid doctor-patient relationship is an important condition. Nonpharmacological intraoperative management should focus on reduction of fear and pain by adaptation of the environment and careful and well considered communication.

Perioperative smoking cessation in vascular surgery: challenges with a randomized controlled trial

Background

The effect of intensive smoking cessation programs on postoperative complications has never before been assessed in soft tissue surgery when smoking cessation is initiated on the day of surgery.

Methods

A single-blinded randomized clinical trial conducted at two vascular surgery departments in Denmark. The intervention group was offered the Gold Standard Program (GSP) for smoking cessation intervention. The control group was offered the departments’ standard care. Inclusion criteria were patients with planned open peripheral vascular surgery and who were daily smokers. According to the power calculation a total of 144 patients were needed in the trial.

Results

Due to slow patient inclusion, the trial was terminated prior to fulfilling the power calculation. Thirty-two patients were included in the trial from March 2011 to September 2012. Of these, 11 were randomized to the GSP intervention and 21 as controls. There was no difference in 30-day complication rates or 6-week abstinence rates between the two groups.

Conclusions

A trial assessing the effect of smoking cessation on postoperative complications on the day of soft tissue surgery is still needed. If another trial is to be planned it must be more pragmatic with less extended inclusion criteria and conducted nationally or internationally to ensure enough patients for the trial.

Trial registration

ClinicalTrials.gov (NCT01469091). Registration date: 27 October 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0965-x) contains supplementary material, which is available to authorized users.

Anesthesia implications of waterpipe use

The waterpipe is an ancient Middle Eastern tobacco delivery system, which is also known as hookah, shisha, or narghile, and it is gaining widespread use. Waterpipes are often perceived as less dangerous than cigarettes. The amount of smoke inhaled in a waterpipe session may equal that produced by more than 100 cigarettes with high nicotine, carbon monoxide, and carcinogen intake. A case of significantly elevated intraoperative carboxyhemoglobin level and decreased oxyhemoglobin saturation in a patient with recent waterpipe use is presented.

Assessment of carbon monoxide values in smokers: a comparison of carbon monoxide in expired air and carboxyhaemoglobin in arterial blood

BACKGROUND AND OBJECTIVE

Smoking increases perioperative complications. Carbon monoxide concentrations can estimate patients' smoking status and might be relevant in preoperative risk assessment. In smokers, we compared measurements of carbon monoxide in expired air (COexp) with measurements of carboxyhaemoglobin (COHb) in arterial blood. The objectives were to determine the level of correlation and to determine whether the methods showed agreement and evaluate them as diagnostic tests in discriminating between heavy and light smokers.

METHODS

The study population consisted of 37 patients. The Micro Smokerlyzer was used to measure COexp; it measures COexp in parts per million (ppm) and converts it to the percentage of haemoglobin combined with carbon monoxide (%Hb). COHb in arterial blood was measured by the ABL 725. Correlation analysis and Bland-Altman analysis were performed, and 2 x 2 contingency tables and receiver operating characteristic curve analysis were conducted.

RESULTS

The correlation between the methods was high (rho = 0.964). Bland-Altman analysis demonstrated that the Micro Smokerlyzer underestimated COHb values. The areas under the receiver operating characteristic curves were 0.746 (ABL 725) and 0.754 (Micro Smokerlyzer) and, by comparison, no statistically significant difference was found (P = 0.815).

CONCLUSION

The two methods showed a high level of correlation, but poor agreement. The Micro Smokerlyzer systematically underestimated COHb values and, in order to avoid this, we suggested an alternative algorithm for converting COexp from ppm to %Hb. The ABL 725 and Micro Smokerlyzer were fair diagnostic tests in distinguishing between heavy and light smokers, but the longer the patients' smoking cessation time, the poorer the ability as diagnostic tests.

Smoking and alcohol intervention before surgery: evidence for best practice

Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3-8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.