Risk of perioperative respiratory complications and postoperative morbidity in a cohort of adults exposed to passive smoking

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.

Smoking is a risk factor for postoperative ileus after radical resection in male patients

Most smokers are males, and smoking has been indicated as a risk factor for many cancers as well as postoperative complications after cancer surgery. However, little is known about whether smoking is a risk factor for postoperative ileus (POI) after radical rectal cancer resection in males. The aim of this study was to assess whether smoking is a risk factor for POI after radical resection in male rectal cancer patients.Data of 1486 patients who underwent radical resection for rectal cancer were extracted from the clinical medical system in our hospital and were statistically analyzed. POI was defined as nausea, vomiting or pain, failure to have bowel function for more than 4 days postoperatively, and absence of a mechanical bowel obstruction.The rate of POI was 12.79%. Univariate analysis showed that patients in the POI group were more likely to have a history of smoking and drinking and receive intraperitoneal chemotherapy and had a larger intraperitoneal chemotherapy dosage. In the multivariable analysis, smoking remained significantly associated with a higher incidence of POI (OR 2.238, 95% CI [1.545-3.240], P = .000). The results also showed that patients who received postoperative patient-controlled intravenous analgesia had a lower incidence of POI.Male patients with a history of smoking who undergo elective radical resection for rectal cancer have an increased risk for POI complications.

PREhabilitation for improving QUality of recovery after ELective cardiac surgery (PREQUEL) study: protocol of a randomised controlled trial

INTRODUCTION

Frailty is a multidimensional syndrome in which multiple small physiological deficits accumulate gradually, resulting in a loss of physiological reserve and adaptability, putting a patient that is exposed to a stressor at a higher risk of adverse outcomes. Both pre-frailty and frailty are associated with poor patient outcomes and higher healthcare costs. The effect of a prehabilitation programme and standard care on the quality of recovery in pre-frail and frail patients undergoing elective cardiac surgery will be compared.

METHOD AND ANALYSIS

A single-centre, superiority, stratified randomised controlled trial with a blinded outcome assessment and intention-to-treat analysis. Pre-frail and frail patients awaiting elective coronary artery bypass graft, with or without valvular repair/replacement, will be recruited. 164 participants will be randomly assigned to either prehabilitation (intervention) or standard care (no intervention) groups. The prehabilitation group will attend two sessions/week of structured exercise (aerobic and resistance) training, supervised by a physiotherapist, for 6-10 weeks before surgery with early health promotion advice in addition to standard care. The standard care group will receive the usual routine care (no prehabilitation). Frailty will be assessed at baseline, hospital admission and at 1 and 3 months after surgery. The primary outcomes will be participants' perceived quality of recovery (15-item Quality of Recovery questionnaire) after surgery (day 3), days at home within 30 days of surgery and the changes in WHO Disability Assessment Schedule 2.0 score between baseline and at 1 and 3 months after surgery. Secondary outcomes will include major adverse cardiac and cerebrovascular events, psychological distress levels, health-related quality of life and healthcare costs.

ETHICS AND DISSEMINATION

The Joint CUHK-NTEC Clinical Research Ethics Committee approved the study protocol (CREC Ref. No. 2017.696 T). The findings will be presented at scientific meetings, in peer-reviewed journals and to study participants.

TRIAL REGISTRATION NUMBER

ChiCTR1800016098; Pre-results.

[Relationship between cigarette smoking and the carbon monoxide concentration in the exhaled breath with perioperative respiratory complications]

BACKGROUND

The purpose of the current study was to determine the effects of preoperative cigarette smoking and the carbon monoxide level in the exhaled breath on perioperative respiratory complications in patients undergoing elective laparoscopic cholecystectomies.

METHODS

One hundred and fifty two patients (smokers, Group S and non-smokers, Group NS), who underwent laparoscopic cholecystectomies under general anesthesia, were studied. Patients completed the Fagerstrom Test for Nicotine Dependence. The preoperative carbon monoxide level in the exhaled breath levels were determined using the piCO+Smokerlyzer 12h before surgery. Respiratory complications were recorded during induction of anesthesia, intraoperatively, during extubation, and in the recovery room.

RESULTS

Statistically significant increases were noted in group S with respect to the incidence of hypoxia during induction of anesthesia, intraoperative bronchospasm, bronchodilator treatment intraoperatively, and bronchospasm during extubation. The carbon monoxide level in the exhaled breath and the Fagerstrom Test for Nicotine Dependence, and number of cigarettes smoked 12h preoperatively were designated as covariates in the regression model. Logistic regression analysis of anesthetic induction showed that a 1 unit increase in the carbon monoxide level in the exhaled breath level was associated with a 1.16 fold increase in the risk of hypoxia (OR=1.16; 95% CI 1.01-1.34; p=0.038). Logistic regression analysis of the intraoperative course showed that a 1 unit increase in the number of cigarettes smoked 12h preoperatively was associated with a 1.16 fold increase in the risk of bronchospasm (OR=1.16; 95% CI 1.04-1.30; p=0.007). While in the recovery room, a 1 unit increase in the Fagerstrom Test for Nicotine Dependence score resulted in a 1.73 fold increase in the risk of bronchospasm (OR=1.73; 95% CI 1.04-2.88; p=0.036).

CONCLUSIONS

Cigarette smoking was shown to increase the incidence of intraoperative respiratory complications while under general anesthesia. Moreover, the estimated preoperative carbon monoxide level in the exhaled breath level may serve as an indicator of the potential risk of perioperative respiratory complications.

Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study

OBJECTIVE

This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery.

SETTING AND PARTICIPANTS

A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities.

OUTCOME MEASURES

The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality.

RESULTS

There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003).

CONCLUSIONS

Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.