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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 75-79

Smoking and Anaesthesia: Implications during perioperative period


Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication26-Mar-2019

Correspondence Address:
Aloka Samantaray
Professor, Department of Anaesthesiology and Critical Care, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_30_18

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  Abstract 


There are considerable myths which surround not only about the different terminology used for smoking but also about their possible impact during the perioperative period. The health hazards posed by smokeless tobacco(electronic cigar) is lower compared to tobacco cigarette smoke whereas actually the levels of aldehydes aerosol generated from new-generation devices at high power levels (Electronic cigars) could approach or even exceed the levels found in cigarette smoke. Nicotine has analgesic properties and thus many believe that smoking tobacco or inhaling nicotine only (e.g., smokeless tobacco) may have a similar effect on pain perceptions in the perioperative period. Many others have opined and associated smoking as a protective factor against postoperative nausea and vomiting. However smoking whether active or passive is always a general health problem and when such patients come for surgery possess additional challenges to the anaesthesiologist. This review will give a brief account of who is a smoker and different terminology being described in literature to describe smoking who need to quit smoking before surgery and when how smoking adversely affects the physiology of body and based on the available literature formulate an anaesthetic plan in smokers.

Keywords: Anaesthesia, Complications, Perioperative, Smoking


How to cite this article:
Samantaray A. Smoking and Anaesthesia: Implications during perioperative period. J Clin Sci Res 2018;7:75-9

How to cite this URL:
Samantaray A. Smoking and Anaesthesia: Implications during perioperative period. J Clin Sci Res [serial online] 2018 [cited 2019 Sep 19];7:75-9. Available from: http://www.jcsr.co.in/text.asp?2018/7/2/75/254972




  Introduction Top


The smoking prevalence in India varies from state to state. In India, annually, about 1 in 10 deaths is projected to be related to smoking in the 2010.[1] The hazard of smoking is not only limited to the general health risks but also make the smokers more vulnerable to various perioperative complications ranging from pulmonary complications to wound healing to cardiovascular events, such as heart attack during hospital stay.[2],[3]

Smokers because of their airway hyper-responsiveness are more prone to coughing during surgery and thus need a higher dose of anaesthesia than non-smokers. Moreover, smokers because of their increase carbon monoxide (CO) level have decreased oxygen delivery to their tissues and are consequently more likely to need oxygen therapy.[4] Many researchers identified smoking as an independent predictor for bad post-operative outcomes, and so, the National Institute for Health and Care Excellence proposed a special service to assist smoker to refrain from smoking and recommends that 'patients referred for elective surgery should be encouraged to stop smoking before an operation.'[5]


  Who is a Smoker? and the Terminology Surrounding Smoking Top


According to the Smoking and Tobacco Use Policy of the World Health Organization (WHO), a smoker is someone who smokes any tobacco products (entirely or partly made of the leaf tobacco as raw material), either daily or occasionally. A daily smoker is someone who smokes any kind of tobacco or tobacco product at least once a day. An occasional smoker is someone who smokes, but not every day.[6]

The National Center for Health Statistics at the Centers for Disease Control and Prevention defines an 'ever smoker' as a person, who has smoked more than equal to 100 cigarettes during their entire life. A 'current smoker' is a subset of ever smoker and includes daily smoker and occasional smoker. A 'former smoker' is a subset of ever smoker, who was not smoking at the time of the interview. A person who was neither smoking at the time of interview nor consumed 100 cigarettes in his life time is called a 'never smoker.'[7] The National Survey on Drug Use and Health (NSDUH) uses a more stringent definition for a current smoker and redefined a current smoker as one who confessed smoking part or all of a cigarette during the 30 days preceding the interview and consumed >100 cigarettes in his life time. Hence, obviously, the prevalence of current smokers yields a higher percentage as per modified NSDUH criteria.[8]

Light smoker: A smoker who confessed consuming between 1 and 10 cigarettes per day. Moderate smoker: A smoker who confessed consuming between 11 and 19 cigarettes per day. Heavy smoker: A smoker who reports consuming 20 cigarettes or more per day.

Electronic nicotine delivery systems

Electronic cigarettes are devices that do not burn or use tobacco leaves but instead vaporise a nicotine solution which the user inhales. The other chemicals present in the nicotine solution used in electronic nicotine delivery systems ( ENDS) are propylene glycol, with or without glycerol and flavouring agents.

Passive smoking or second-hand smoking

It is an involuntary or unintentional inhalation of a mixture of the smoke coming off directly from the burnt tobacco and the smoke exhaled by smokers. As these smokes are unfiltered, they contain more carcinogenic and more irritant materials and possess a greater health hazard than active smoking.

Waterpipe smoking or 'hukka'

They contain more nicotine (2%–4% vs. 1%–3%) and higher CO concentration (0.34%–1.4% vs. 0.41%) than cigarette.


  Who Need to Quit Smoking and When? Top


Considering the fact that smoking is a general public health concern, it is advisable to stop smoking whether somebody need to undergoes a surgery or not. There is an ill-founded study that stopping smoking shortly before surgery may increase complications.[9] However, a recent meta-analysis did not substantiate such finding and concludes no association between overall post-operative complications rate in general and pulmonary complications rate in particular amongst smokers who quit within 2 months of surgery.[10] Quitting smoking at any time before or after surgery is always beneficial for the patients.[11] Stopping smoking even for 1 day before surgery helps in improving tissue oxygen delivery by reducing the carboxyhaemoglobin (COHb) levels and thereby shifting the oxygen dissociation curve to the right. However, to reduce the volume of sputum production, one needs to quit smoking at least for 1–2 weeks.[12] Abstinence of at least 3–4 weeks is needed to reduce complications related to effective wound healing.[13] Most investigators suggest that stopping smoking 2 months before surgery provides the maximum benefit.[10],[14],[15]


  How Smoking Adversely Affects the Body Physiology? Top


There are several toxic substances that can be isolated from cigarette smoke.[16] Nicotine and CO are the two toxic substances in cigarette smoke which bring undesirable imbalance in physiological response. The other toxic substances present in cigarette smoke are nitrogen oxides, volatile aldehydes, alkenes and hydrogen cyanide and polyacrylic aromatic hydrocarbons. In smokers, there are no changes in the action of volatile agents, but increased metabolism can lead to higher levels of toxic metabolites.[17]

Cardiovascular system

Nicotine stimulates the adrenal medulla to secrete adrenaline which in turn stimulates the sympathetic system. The resultant increases in heart rate, blood pressure, contractility and peripheral vascular resistance imbalances the myocardial oxygen supply-demand ratio which makes the heart vulnerable for ischaemic damage. The ischaemic myocardial damage is further compounded by raised intracellular calcium, a response to nicotine stimulation.[18]

CO reversibly binds with cytochrome oxidase and myoglobin and inactivates the myocardial mitochondrial enzyme system. This results in decreased intracellular oxygen transport and utilisation which further leads to chronic tissue hypoxia and negative inotropic effects on vascular system.

The half-life of nicotine and COHb are 30–60 min and 4–6 h, respectively.[18] The elimination of effects of nicotine depends on abstinence from smoking whereas that of CO depends chiefly on pulmonary ventilation.[19] Hence, abstinence from smoking even a brief period (4–6 h) can eliminate the harmful effects of nicotine and CO and brings a favourable myocardial oxygen-demand supply ratio. The author believes that smokers presenting for emergency surgery or are unable to quit smoking till they have been scheduled for elective surgery should be advised to refrain from smoking on the day of the operation.

Respiratory system

The substances in tobacco and tobacco smoke may cause harm even at low levels of exposure. The irritants and ciliotoxins present in tobacco smoke increases mucous production and weakens the mucus clearance mechanism in the tracheobronchial tree.[20] This results in complete paralysis of the defence mechanism of the respiratory tract and leads to clogging of the lungs with hyper-viscous thick mucus secretion, bacteria and dead cells. This makes the lungs vulnerable to various infections.[14],[21] The irritant smoke damages the lung epithelium which result in small airway narrowing (decreased closing volume), chronic bronchitis. In addition to damaged epithelium an increase in proteolytic and elastolytic enzymes leads to loss of elasticity and emphysema. All these pathological changes leads impaired gas exchange function.[22] Furthermore, CO in the cigarette smoke binds to haemoglobin replacing oxygen with COHb up to 7%–15% and this shifts the oxygen dissociation curves to left and will reduce oxygen availability to tissues.[23] The strong affinity of CO for binding to haemoglobin (250 times more than that of oxygen) can be offset by allowing the patients to breath 100% oxygen before anaesthesia induction which expedite the removal of CO from haemoglobin.

Increased airway reactivity due to smoke irritants predisposes the patient to frequent episodes of breath holding, laryngeal spasm, bronchospasm, hypoventilation and hypoxia during anaesthesia induction and emergence.

Gastrointestinal system

Smoking as such has no direct effect on the gastric volume or the pH of gastric secretions and do not increases the risk for pulmonary aspiration. However, smoking may relaxes the gastro-oesophageal sphincter, but this too returns to normal within minutes after stopping.

Renal system

Smoking results in increased secretion of anti-diuretic hormone leading to dilutional hyponatraemia.

Hepatic system

The pharmacokinetics and pharmacodynamics of drugs being metabolised in the liver become unpredictable because of induction of liver microsomal enzymes because of smoke. Smoking also enhances biotransformation of many drugs that share cytochrome P-450 mixed oxidase pathway. Few authors have studied the relation between smoking and need for opioid analgesics. Smokers neither have a lower threshold for pain nor do they need less analgesia than non-smokers. A recent study indicated a higher rate of consumption of opioids among smokers compared to non-smokers.[24] These authors also found a statistically non-significant higher post-operative pain score (measured with visual analogue scale). However, other investigators did not find any such difference in pain perception or analgesic requirement between smokers and non-smokers.[25]

Neuromuscular junction

The potency of amino steroid muscle relaxants (rocuronium and vecuronium) decreases in smoker. Although the exact mechanism is not clear, altered pharmacodynamics leading to either resistance or increased metabolism of drug at the receptor site has been suggested.[26],[27] Smokers who refrain from smoking for more than 10 h require a smaller maintenance dose of atracurium than non-smokers. However, using a transdermal nicotine system prevents the decrease in maintenance dose of atracurium during abstinence.[28]

Immunological function

There is well-documented evidence that smoking impairs humoral activity and cell-mediated immunity and decreases immunoglobulin and leucocyte activity. All this predisposes the smoker to increased risk of increased risk of infection and malignancy.[20]


  Anaesthesia Planning Top


Pre-operative assessment

Patients are advised to stop smoking on their first pre-operative visit. Abstinence of 8 weeks derives the most benefits of stopping smoking. However, an abstinence for 12–14 h improves ciliary function and brings down the nicotine level to normal; abstinence for 2 weeks helps return sputum volume to normal levels; abstinence for 5–10 days improves laryngeal and bronchial activity; abstinence for 4 weeks reduces early small airway closure; abstinence for 3 months maximise tracheobronchial clearance. A small subset of patients exhibits anxiety and nicotine withdrawal symptoms and they need to be reassured and treated symptomatically.

Regional anaesthesia

Many of the smokers have a reactive airway and are prone to severe bronchospasm and desaturation during airway manipulation during general endotracheal anaesthesia. Patients suitable for regional anaesthesia should be identified and a suitable regional analgesia technique is used. Although central neuraxial block produces bronchodilation, a high-level sensory-motor blockade may result in difficulty in breathing by abolishing expiratory muscle power. Furthermore, this adds to patient anxiety and may lead to bronchospasm and subsequent respiratory failure may occur.[29]

Induction of anaesthesia

Anaesthesia induction should be preceded by pre-oxygenation with 100% oxygen routinely. The need for tracheal intubation should always be anticipated while using supraglottic airway devices or total intravenous anaesthesia in lieu of hyperactive airway. Adequate depth of anaesthesia at the time of laryngoscopy and tracheal intubation has to be maintained to minimise the risk of inciting a bronchospasm.

Anaesthetic drugs

Smokers may need an additional dose of amino-steroid neuromuscular blocking agents because of altered pharmacodynamics at the neuromuscular junction receptors. Adequate and appropriate analgesia in the form of epidural analgesia should be considered, especially in patients undergoing thoracic and upper abdominal surgeries in lieu of their beneficial role in preventing post-operative pulmonary complications.

Post-operative period

Early mobilisation is encouraged whenever feasible to improve lung function and sputum clearance.

Post-operative nausea and vomiting

It is speculated that smokers may have developed some tolerance because of the chronic emetogenic influence of nicotine, which is lacking in the non-smoker.[30] An Indian study[24] though validated the finding by Cohen et al.[30] failed to demonstrate any significant difference in the occurrence of post-operative nausea and vomiting between heavy smokers (more than 20 cigarettes daily) and smokers (less than 20 cigarettes daily).

Post-operative pain

The interaction of smoking and post-operative analgesic requirement involves a complex mechanism. The result from various human studies varies based on patients smoking habit, type of pain stimulus, and gender.[31],[32],[33],[34]

It appears that in most studies of humans who do not smoke, nicotine has anti-nociceptive effects in a clinical setting, but in smokers, receptor desensitisation and/or withdrawal effects may limit any analgesic effects of perioperative nicotine administration.[35]

Both active and passive smoking can influence the analgesic requirement in the post-operative period. Smokers not only have a higher pain score in the post-operative period but are also more prone to develop chronic painful conditions.[36],[37],[38]

Smoking is a health hazard and no amount of smoking is safe. Anaesthesiologist as a responsible caretaker of national/global health should involve himself/herself actively to counsel the patients against smoking in any form.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
Introduction
Who is a Smoker?...
Who Need to Quit...
How Smoking Adve...
Anaesthesia Planning
References

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