The patient comes to your perioperative clinic 2 weeks before surgery. He wants to know if his smoking puts him at increased risk during surgery. What do you tell him? Should he quit now?
Answer:
Smoking results in increased levels of carboxyhemoglobin, lower oxygen content, and decreased delivery of oxygen by hemoglobin to the tissues. These effects are dramatically improved with as little as 12 hours of smoking cessation.
Smoking also increases the risk of PPCs, which include respiratory failure, unplanned intensive care unit (ICU) admission, pneumonia, airway events during anesthesia, and increased need for postoperative respiratory support. Smokers have an increased rate of wound-related complications and decreased bone healing after surgery. Although a cessation period of at least 8 weeks prior to surgery is optimal and results in improved mucociliary clearance, decreased sputum production, and a relative risk reduction in PPCs, it is highly recommended for patients to stop smoking at any time prior to surgery.
A persistent misconception in our specialty is that short-term smoking cessation (<4 weeks) is detrimental to the patient. Some have argued that a patient smoking 2 weeks before surgery should continue smoking to avoid increased risks associated with cessation. There is now a preponderance of evidence that debunks this myth. Short-term smoking cessation is not a risk factor for long-term perioperative complications. In contrast, the long-term detrimental effects of continued smoking are well known. Anesthesiologists should be aware that admission for surgery can be a powerful motivator for patients to quit smoking, providing a 'teachable moment' for smoking cessation and frequently resulting in successful, long-term cessation. Therefore, this patient should be counseled to quit smoking as soon as possible.
Reference(s):
- Myers K, Hajek P, Hinds C, et al. Stopping smoking shortly before surgery and postoperative complications. Arch Intern Med. 2011;171(11):983-989.
- Turan A, Mascha EJ, Roberman D, et al. Smoking and perioperative outcomes. Anesthesiology. 2011;114:837-846.
- Warner DO. Perioperative abstinence from smoking: physiologic and clinical consequences. Anesthesiology. 2006;104:356-367.
- Yu S, Warner DO. Surgery as a teachable moment for smoking cessation. Anesthesiology. 2010;112:102-107.