Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi-center study

Incidence and risk factors of postoperative nausea and vomiting following laparoscopic sleeve gastrectomy and its relationship with Helicobacter pylori: A propensity score matching analysis

BACKGROUND

Postoperative nausea and vomiting (PONV) are common after laparoscopic sleeve gastrectomy (LSG), affecting patient satisfaction and postoperative recovery. The purpose of this study was to investigate the incidence and severity of PONV after LSG and the relationship between Helicobacter pylori (HP) and PONV.

METHODS

Patients undergoing LSG in our center from June 1, 2018, to May 31, 2022, were divided into HP-positive and HP-negative groups for retrospective analysis. The independent risk factors of PONV were determined by univariate and binary logistic regression analysis using a 1:1 propensity score matching (PSM) method.

RESULTS

A total of 656 patients was enrolled, and 193 pairs of HP-positive and negative groups were matched after PSM. Both groups of patients had similar clinical features and surgical procedures. PONV occurred in 232 patients (60.1%) after LSG, and the incidence of PONV in HP-positive patients was 61.10%. The incidence and severity of PONV were statistically similar in both groups (P=0.815). Multivariate analysis showed that the female sex (OR=1.644, P=0.042), postoperative pain (OR=2.203, P=0.001) and use of postoperative opioid (OR=2.229, P=0.000) were independent risk factors for PONV after LSG, whereas T2DM (OR=0.510, P=0.009) and OSAS (OR=0.545, P=0.008) independently reduced the incidence rate of PONV. There was no difference either in smoking (P=0.255) or alcohol drinking (P=0.801). HP infection did not affect PONV (P=0.678).

CONCLUSIONS

The incidence of PONV following LSG was relatively high. Female sex, postoperative pain and use of postoperative opioid predicted a higher incidence of PONV. Patients with T2DM and OSAS were less likely to have PONV. There was no clear association between HP infection and PONV after LSG.

Predictors of severe postoperative pain after orthopedic surgery in the immediate postoperative period

AIM

Severe pain in the immediate postoperative period can negatively affect patients' quality of recovery, prolong hospital stay, and increase the risk of developing persistent pain. This study aimed to examine the predictors of severe postoperative pain in the immediate postoperative period among orthopedic trauma patients.

METHODS

A prospective observational study design was used. Data were collected from 153 patients that underwent orthopedic surgery procedures. Pain scores were assessed by a numeric pain scale at 45 min in the Post Anesthesia Care Unit. Physical health status was measured by the American Society of Anesthesiologists Status Classification System, and total dose of opioids (converted to morphine equivalents) and other demographic and clinical characteristics were recorded from medical records.

RESULTS

Preoperative smoking and physical health status were statistically significant predictors of severe postoperative pain in the immediate postoperative period. The odds of severe postoperative pain for smokers were 2.42 times the odds of nonsmokers. Patients with severe systemic disease showed 4.27 times lower odds of severe pain than more healthy patients.

CONCLUSION

Preoperative predictors of severe postoperative pain should be considered when assessing and treating orthopedic patients postoperatively to assure adequate pain relief.

Effect of preoperative smoking cessation on postoperative pain outcomes in elderly patients with high nicotine dependence

OBJECTIVE

To investigate the effect of smoking cessation before surgery on postoperative pain and analgesic consumption after thoracoscopic radical resection of lung cancer in elderly patients with high nicotine dependence.

METHODS

A total of 107 male patients, ages 60 to 70 years, undergoing elective thoracoscopic radical lung cancer surgery from July 2017 to July 2018 were enrolled into 3 groups: group A (highly nicotine-dependent and discontinued smoking <3 weeks before surgery, n = 36), group B (highly nicotine-dependent and discontinued smoking >3 weeks before surgery, n = 38), and group C (nonsmokers, n = 33). Postoperative sufentanil consumption, visual analog scale (VAS) pain scores at rest and during cough, rescue analgesia, opioid-related adverse events, and patient satisfaction were assessed from 0 to 48 h postoperatively.

RESULTS

Patient characteristics were comparable among the 3 groups. Sufentanil consumption and VAS pain scores from postoperative 0 to 48 h were significantly higher in groups A and B than in group C. In addition, group B had lower sufentanil consumption and pain scores than group A. No differences in the need for rescue analgesia, patient satisfaction, or occurrence of postoperative adverse events, including nausea, vomiting, respiratory depression, and oversedation, were observed among the 3 groups.

CONCLUSION

Compared with nonsmokers, highly nicotine-dependent male patients who were deprived of cigarettes experienced more severe pain and required treatment with more sufentanil after thoracoscopic radical lung cancer surgery. Moreover, preoperative smoking cessation at least 3 weeks before surgery led to better postoperative pain outcomes than smoking cessation within 3 weeks of surgery.

Factors Affecting Postoperative Nausea and Vomiting in Surgical Patients

PURPOSE

This study was to identify factors affecting postoperative nausea and vomiting (PONV) and to investigate the incidence of PONV for the first 24 hours after operation.

DESIGN

The prospective research was performed in an 1,100-bed university hospital, from April to December, 2011. The sample consisted of 609 patients with elective surgery.

METHODS

Factors affecting PONV were identified by multiple logistic regression.

FINDINGS

Incidence of PONV was 27.1% for the first postoperative 24 hours. Insertion of nasogastric tube (OR, 4.54, P = .002), history of PONV (OR, 3.24, P < .001), general anesthesia (OR, 2.76, P = .002), history of motion sickness (OR, 2.33, P < .001), and female sex (OR, 2.05, P = .004) were high risk factors of PONV. The nonadministration of antiemetics during operation (OR, 1.70, P = .014) and nonuse of intravenous patient-controlled analgesia (OR, 1.54, P = .038) increased PONV during the first postoperative 24 hours.

CONCLUSIONS

Patients of female gender, history of motion sickness and PONV, general anesthesia, and nasogastric insertion are more likely to experience PONV.

Intranasal or transdermal nicotine for the treatment of postoperative pain

BACKGROUND

Acute pain frequently occurs after surgical procedures. Nicotine has been explored as an adjunctive medication for management of postoperative pain.  

OBJECTIVES

To assess the effect of transdermal or intranasal nicotine administration on postoperative pain, opioid analgesic use, and opioid-related adverse events.  

SEARCH METHODS

We searched MEDLINE (1966 to 20 March 2014), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 3), EMBASE (1980 to 20 March 2014), and also databases of ongoing trials (www.controlled-trials.com/ and http://clinicaltrials.gov/). We re-ran the search on 28 April 2015. We will assess the one study of interest when we update the review.

SELECTION CRITERIA

We included randomized, placebo-controlled clinical trials that evaluated the effects of perioperative (pre-, intra-, or postoperative) administration of nicotine on postoperative pain, opioid use, and opioid-related adverse events. We excluded all other studies.

DATA COLLECTION AND ANALYSIS

Two authors independently screened all titles and abstracts for eligibility and documented reasons for exclusion. In case of disagreement, a third author decided on the inclusion or exclusion of a trial report. When additional information was needed in order to decide if a trial should be included, one of the authors contacted the corresponding author of the trial in question.

MAIN RESULTS

Nine trials (666 participants) evaluated nicotine for postoperative pain. Nicotine may reduce postoperative pain scores at 24 hours by a small amount compared with placebo (eight trials, mean difference -0.88 on a 0 to 10 scale, 95% confidence interval (CI) -1.58 to -0.18; low quality evidence). The effect on pain at one hour and 12 hours postoperatively was less certain (very low quality evidence). Statistical heterogeneity was substantial and not adequately explained by stratification of trials according to type of surgical procedure, smoking status, mode of nicotine administration, timing of administration, or assessed risk of bias. Excluding one trial at high risk of bias resulted in similar findings. The effect of nicotine on postoperative opioid use was uncertain due to small number of participants in the studies. Nicotine probably increases the risk of postoperative nausea (seven trials, RR 1.24, 95% CI 1.03 to 1.50; moderate quality evidence). Three trials assessed sedation but the effect is very uncertain due to the very low quality of evidence. We found no evidence that nicotine increased the risk of vomiting (seven studies, risk difference (RD) 0.03, 95% CI -0.04 to 0.09; low quality evidence). The results from one single small trial were insufficient to establish whether nicotine led to an earlier hospital discharge (very low quality evidence).

AUTHORS' CONCLUSIONS

Based on evidence of generally low quality, nicotine may reduce postoperative pain at 24 hours compared with placebo, but the effects were relatively small (less than 1 point on a 10 point pain scale) and there was substantial heterogeneity in the results of our analyses. Nicotine does not appear to reduce postoperative use of opioids or opioid-related adverse events but probably increases the risk of nausea. More research is needed to determine the effectiveness of nicotine for postoperative pain and to understand the optimal timing, dose, and method of delivery of nicotine.

Preoperative platelet count and volume could not help predict PONV in women undergoing breast cancer surgery: A prospective cohort study

Postoperative nausea and vomiting (PONV) still represents one of the most distressing side effects of anaesthesia and surgery. Clinical risk scores e.g. Apfel score is today commonly used to identify patients at risk. We found in a previous study different platelet counts in patients with and without PONV. The aim of the present explorative study was to assess whether females experiencing PONV after breast surgery had any difference in preoperative platelet count and/or volume assessed by platelet testing.

METHODS

All women scheduled for elective breast cancer surgery at Danderyds Hospital, Stockholm, Sweden, during one year were asked to participate in this study. Occurrence of PONV during the 24 first postoperative hours was studied. Blood samples collected preoperatively were analysed by platelet counts determined by impedance (PTLi) and optical (PTLo) methods, mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PCT). Platelet data were compared between patients with and without PONV.

RESULTS

In all 183 patients were included in the study, 65 (35%) suffered from PONV, increasing incidence with increased risk score 4 out 5 with 4 risk factors. Mean platelet count was 266 [114-538], mean platelet volume 8.59 [5.94-12.1] and mean platelet weight 16.17 [14.2-25.9] but no differences in any platelet test variables studied were found between patients with or without PONV or with increasing risk factors.

CONCLUSION

One third of patients' experienced PONV, increased incidence associated to Apfel score but platelet numbers and simple platelet test provided no additional information around risk for PONV.

Effect of nicotine dependence on opioid requirements of patients after thoracic surgery

BACKGROUND

This retrospective study investigated the effect of nicotine dependence on required postoperative opioid administration in patients undergoing thoracic surgery.

METHODS

The subjects consisted of 215 male patients (112 nonsmokers, 103 smokers) who underwent thoracic surgery and received postoperative patient-controlled intravenous analgesia. Evaluations of nicotine dependence were based on results of Fagerstrom Test of Nicotine Dependence (FTND) questionnaires. Smokers were categorized as low-nicotine dependent (LD) (n = 58) or highly-nicotine dependent (HD, n = 45) with FTND scores < 6 or ≥ 6, respectively. Pain intensity was assessed every 2 h after surgery, using the numerical rating scale (NRS). The cumulative amount of self-administered sufentanil at 24 and 48 h after surgery was recorded.

RESULTS

There were no significant differences in baseline clinical characteristics among the nonsmoker (NS), LD, and HD groups. The NRS scores and total amount of self-administered sufentanil were significantly higher in the HD and LD groups compared with the NS group, and were significantly higher in the HD group than in the LD group. The FTND scores positively correlated with the cumulative quantity of sufentanil. Postoperative complications such as nausea and vomiting, sedation, and respiratory depression did not significantly differ among the groups.

CONCLUSIONS

Smokers had more severe postoperative pain and required a higher quantity of postoperative opioid than nonsmokers. With increasing nicotine dependence, postoperative pain severity and postoperative opioid requirement increased.

Nicotine gum chewing: a novel strategy to shorten duration of postoperative ileus via vagus nerve activation

Postoperative ileus (POI) is a transit cessation of bowel motility after surgery. Substantial evidences suggest that gum chewing accelerate the recovery of bowel motility after surgery. Perioperative nicotine administration reduces postoperative opioid use and prevents postoperative nausea and vomiting. Nicotine gum chewing combines stimulation of the cephalic-vagal reflex by gum chewing, and activation of the cholinergic anti-inflammatory pathway by nicotine administration. We therefore hypothesized that nicotine gum chewing reduces POI and improves patient outcomes such as shortening the length of hospitalization as well as saving medical costs. As nicotine gum is commercially available, inexpensive, and has been in use for many years without any severe side effects, it may have a wide clinical application in POI prevention.

Risk factors for clinician-reported symptom clusters in patients with advanced head and neck cancer in a phase 3 randomized clinical trial: RTOG 0129

BACKGROUND

Chemoradiotherapy has become the standard of care for head and neck squamous cell carcinoma; however, those patients often experience multiple treatment-related symptoms or symptom clusters. Two symptom clusters have been identified for this population. Little is known about the risk factors of these symptom clusters.

METHODS

Subjects comprised 684 patients who were treated with concurrent chemoradiotherapy in a phase 3 randomized clinical trial. This trial compared standard fractionation radiotherapy to accelerated fractionation radiotherapy. Symptom clusters were evaluated at the end of the first and the second cycle of chemotherapy, and 3 months after the start of radiotherapy. Mixed-effect modeling was used to observe risk factors for symptom clusters.

RESULTS

Race and education were independent predictors for the head and neck cluster, whereas sex and history of tobacco use were independent predictors for the gastrointestinal cluster. Primary cancer site was only significant for the head and neck cluster when other factors were not controlled: patients with oropharyngeal cancer had more severe symptoms in the head and neck clusters than did patients with laryngeal cancer. In addition, patients receiving accelerated fractionation radiotherapy experienced more symptoms of radiomucositis, pain, and nausea at 3 months after the start of radiotherapy than those receiving standard fractionation radiotherapy.

CONCLUSIONS

Demographic characteristics were more predictive to symptom clusters, whereas clinical characteristics, such as cancer site and treatment arms, were more significant for individual symptoms. Knowing the risk factors will enhance the capability of clinicians to evaluate patients' risk of severe symptom clusters and to personalize management strategies.

Nausea and vomiting after surgery: it is not just postoperative

PURPOSE OF REVIEW

The purpose of this review is to highlight postoperative nausea and vomiting (PONV), to discuss why it occurs, how it might be prevented and then how it can be treated.

RECENT FINDINGS

PONV/postdischarge nausea and vomiting (PDNV) is a problem that patients identify as one of the worst, if not the worst problem that can occur after surgery. Therapy is not perfect, yet there are anaesthesia techniques that can help minimize the problem and drugs that can be used both to prevent and also treat the problem once it occurs. There is a genetic basis for why some people experience PONV/PDNV more than others and also why treatment for some is better than others.

SUMMARY

It is easy to turn the vapourizer dial, but that is a part of the problem. Not everyone reacts the same to drugs. Although PDNV is not as well characterized as PONV, at the very least, avoid an anaesthetic that may make PONV/PDNV worse and be aggressive in treating the problem.

The association of CYP2D6 genotype and postoperative nausea and vomiting in orthopedic trauma patients

The CYP2D6 gene encodes for an enzyme that is involved in the metabolism of more than 25% of all medications, including many opioids and antiemetics. It may contribute to the risk of postoperative nausea and vomiting (PONV), a common surgical complication. However, little research has been conducted in this area. The purpose of this study was to explore the association of CYP2D6 genotypes with PONV in adult surgical trauma patients. Data from 112 patients (28% female) with single extremity fractures, aged 18-70 years, were analyzed. PONV was defined as present if patients reported nausea, were observed vomiting, or received medication for PONV. Saliva samples collected for DNA extraction and Taqman(®) allele discrimination and quantitative real time polymerase chain reaction (qRT-PCR) were used to collect genotype data that were then used to assign CYP2D6 phenotype classification. The incidence of PONV was 38% in the postanesthesia care unit and increased to 50% when assessed at 48 hr. CYP2D6 classification results were 7 (6%) poor metabolizers, 34 (30%) intermediate metabolizers, and 71 (63%) extensive metabolizers. No ultrarapid metabolizers were identified. Patients who were classified as poor metabolizers had less PONV and higher pain scores. Gender and history of PONV, but not smoking, were also significant risk factors. Findings suggest variability in CYP2D6 impacts susceptibility to PONV.

Preoperative evaluation of the surgical patient

A thorough preoperative evaluation to identify correctable medical abnormalities and understand the residual risk is mandatory for all patients undergoing any surgical procedure, including oral surgery. Routine preoperative evaluation will vary among patients, depending on age and general health. This article addresses the preoperative evaluation of surgical patients in general, and the evaluation for general anesthesia in the operating room.

Headache following intracranial neuroendovascular procedures

AIMS

Predicting who will develop post-procedure headache (PPH) following intracranial endovascular procedures (IEPs) would be clinically useful and potentially could assist in reducing the excessive diagnostic testing so often obtained in these patients. Although limited safety data exist, the use of triptans or dihydroergotamine (DHE) often raise concern when used with pre/post-coiled aneurysms. We sought to determine risk factors for PPH following IEP, to evaluate the utility of diagnostic testing in patients with post-coil acute headache (HA), and to record whether triptans and DHE have been used safely in this clinical setting.

METHODS

We conducted a retrospective chart review of adult patients undergoing IEPs. Bivariate analyses were conducted to compare patients who did and did not develop PPH.

RESULTS

We reviewed records pertaining to 372 patients, of whom 263 underwent intracranial coil embolizations, 21 acrylic glue embolizations, and 88 stent placements. PPH occurred in 72% of coil patients, 33% of glue patients, and 14% of stent patients. Significant risk factors for post-coil HA were female gender, any pre-coil HA history, smoking, and anxiety/depression. A pre-stent history of HA exceeding 1 year's duration, and smoking were risk factors for post-stent HA. A pre-glue history of HA exceeding 1 year was the only risk factor for post-glue HA. In the small subgroup available for study, treatment with triptans or DHE was not associated with adverse events in pre/post-coiled aneurysms. Diagnostic testing was low yield.

CONCLUSIONS

Occurrence of PPH was common after IEPs and especially so with coiling and in women, smokers, and those with anxiety/depression, and was often of longer duration than allowed by current International Classification of Headache Disorders-II criteria. The yield of diagnostic testing was low, and in a small subgroup treatment with triptans or DHE did not cause adverse events in pre/post-coiled aneurysms. Prospective studies are needed to confirm these findings.

Transcutaneous nicotine does not prevent postoperative nausea and vomiting: a randomized controlled trial

AIMS

There is empirical evidence that smokers are less likely to suffer from postoperative nausea and vomiting (PONV). We sought to investigate whether transcutaneus nicotine prevents PONV.

METHODS

Non-smokers receiving general anaesthesia for surgery were randomly allocated to Nicotinell Patch 10cm(2) (TTS 10), containing 17.5mg of nicotine (average delivery rate, 7mg 24h(-1) ) or matching placebo patch. Patches were applied 1h before surgery and were left in situ until 24h after surgery (or until the first PONV symptoms occurred).

RESULTS

We randomized 90 patients (45 nicotine, 45 placebo). In the post-anaesthetic care unit, the incidence of nausea was 22.2% with nicotine and 24.4% with placebo (P= 0.80), and the incidence of vomiting was 20.0% with nicotine and 17.8% with placebo (P= 0.78). Cumulative 24h incidence of nausea was 42.2% with nicotine and 40.0% with placebo (P= 0.83), and of vomiting was 31.1% with nicotine and 28.9% with placebo (P= 0.81). PONV episodes tended to occur earlier in the nicotine group. Postoperative headache occurred in 17.8% of patients treated with nicotine and in 15.6% with placebo (P= 0.49). More patients receiving nicotine reported a low quality of sleep during the first postoperative night (26.7% vs. 6.8% with placebo; P= 0.01).

CONCLUSIONS

Non-smokers receiving a prophylactic nicotine patch had a similar incidence of PONV during the first 24h and tended to develop PONV symptoms earlier compared with controls. They had a significantly increased risk of insomnia during the first postoperative night.

Summary of the epidemiological evidence relating snus to health

Interest in snus (Swedish-type moist snuff) as a smoking alternative has increased. This wide-ranging review summarizes evidence relating snus to health and to initiation and cessation of smoking. Meta-analyses are included. After smoking adjustment, snus is unassociated with cancer of the oropharynx (meta-analysis RR 0.97, 95% CI 0.68-1.37), oesophagus (1.10, 0.92-1.33), stomach (0.98, 0.82-1.17), pancreas (1.20, 0.66-2.20), lung (0.71, 0.66-0.76) or other sites, or with heart disease (1.01, 0.91-1.12) or stroke (1.05, 0.95-1.15). No clear associations are evident in never smokers, any possible risk from snus being much less than from smoking. "Snuff-dipper's lesion" does not predict oral cancer. Snus users have increased weight, but diabetes and chronic hypertension seem unaffected. Notwithstanding unconfirmed reports of associations with reduced birthweight, and some other conditions, the evidence provides scant support for any major adverse health effect of snus. Although some claims that snus reduces initiation or encourages quitting are unsoundly based, snus seems not to increase initiation, as indicated by few smokers using snus before starting and current snus use being unassociated with smoking in adults (the association in children probably being due to uncontrolled confounding), and there are no reports that snus discourages quitting.

The effect of smoking nicotine tobacco versus smoking deprivation on motion sickness

BACKGROUND

The experienced smoker maintains adequate nicotine levels by 'puff-by-puff self-control' which also avoids symptomatic nauseating effects of nicotine overdose. It is postulated that there is a varying 'dynamic threshold for nausea' into which motion sickness susceptibility provides an objective toxin-free probe. Hypotheses were that: (i) nicotine promotes motion sickness whereas deprivation protects; and (ii) pleasurable effects of nicotine protect against motion sickness whereas adverse effects of withdrawal have the opposite effect.

METHODS

Twenty-six healthy habitual cigarette smokers (mean ± SD) 15.3 ± 7.6 cigs/day, were exposed to a provocative cross-coupled (coriolis) motion on a turntable, with sequences of 8 head movements every 30s. This continued to the point of moderate nausea. Subjects were tested after either ad-lib normal smoking (SMOKE) or after overnight deprivation (DEPRIV), according to a repeated measures design counter-balanced for order with 1-week interval between tests.

RESULTS

Deprivation from recent smoking was confirmed by objective measures: exhaled carbon monoxide CO was lower (P<0.001) for DEPRIV (8.5 ± 5.6 ppm) versus SMOKE (16.0 ± 6.3 ppm); resting heart rate was lower (P<0.001) for DEPRIV (67.9 ± 8.4 bpm) versus SMOKE (74.3 ± 9.5 bpm). Mean ± SD sequences of head movements tolerated to achieve moderate nausea were more (P = 0.014) for DEPRIV (21.3 ± 9.9) versus SMOKE (18.3 ± 8.5).

DISCUSSION

Tolerance to motion sickness was aided by short-term smoking deprivation, supporting Hypothesis (i) but not Hypothesis (ii). The effect was was approximately equivalent to half of the effect of an anti-motion sickness drug. Temporary nicotine withdrawal peri-operatively may explain why smokers have reduced risk for postoperative nausea and vomiting (PONV).