• Anaesthetists commonly encounter patients with both short and long term sequelae of smoking and its associated pulmonary and cardiovascular complications in the perioperative period.
• An upcoming surgery can provide an opportunity and motivation to quit smoking for ever, as patients are forced to abstain due to non-smoking policies that are practiced by hospitals. Thus, if possible, anaesthetists should play a role in counseling preoperatively, and as healthcare providers, have a responsibility to advise for permanent cessation.

• Smoke from tobacco has more than 25 carcinogens, though the most damaging products are nicotine, tar, and carbon monoxide. The particulate phase contains at least 3,500 compounds, mostly carcinogens and free radicals.
• Tobacco has nicotine (2–5%), sugars (mainly reduced) (8–25%), and moisture (10–14%).

Nicotine stimulates preganglionic autonomic receptors, resulting in the release of epinephrine from adrenal glands, norepinephrine from nerve endings, and dopamine and endorphins from the central nervous system. They are responsible for different perceptions and behaviors, including the euphoria associated with smoking. Hence, it is a highly addictive substance.

Smoking cessation: Ideally smoking should be stopped 8 weeks prior to surgery (patients should be advised at the surgeon's office or at the time of scheduling). If that does not occur or the patient is unable to stop, abstinence should be recommended for at least 24 hours prior to surgery, or the evening before surgery to decrease the deleterious effects of nicotine and carbon monoxide.

COPD and cardiovascular symptomatology should be sought.

Counseling

• Nicotine replacement therapy
• Bupropion, an atypical antidepressant

• Pulmonary system: Most common cause of lung carcinoma and COPD. Perioperatively, smoking increases airway irritability, sensitizes the reflex responses to chemical irritants, and increases mucus production. Bronchial mucus transport during general anesthesia is further slowed in smokers compared with nonsmokers. Carbon monoxide decreases oxygen binding to hemoglobin and thus decreases overall blood oxygen content. Smoking is associated with increased incidences of perioperative laryngospasm, bronchospasm, episodes of desaturation, development of pneumonia, respiratory failure and unanticipated ICU admission and requirement of ventilatory support.
• Cardiovascular system. Increases the risk of developing CAD, cerebrovascular disease, and stroke by 2–4 times. By accelerating atherosclerosis, it indirectly contributes to perioperative cardiac morbidity and mortality. Carbon monoxide present in smoke can injure myocardium due to chronic exposure and increases the myocardium's susceptibility to viral infections, cardiomyopathy, and CHF. Perioperatively, smoking increases heart rate, BP, and myocardial contractility, thereby increasing myocardial work and oxygen consumption. It also increases plasma levels of catecholamines.
• Hepatic system. Induces the liver microsomal enzymes; thus, medications that undergo hepatic metabolism may require increased dosing (e.g., benzodiazepines and morphine)
• Endocrine system: Increases secretion of antidiuretic hormone resulting in dilutional hyponatremia
• Hematologic system: Associated with increase in production of hemoglobin, RBCs, WBCs, platelets, and fibrinogen. Despite an increased incidence of thromboembolic disease in smokers, the relative risk of deep venous thrombosis (DVT) is not higher than that of nonsmokers.
• Wound and bone healing. Impairs immune response. Smokers are more likely to develop postoperative complications related to wound healing such as dehiscence and infection. It also has been shown to contribute to impairment of bone healing and nonunion of spinal fusions. In patients undergoing knee and hip replacements, smoking cessation decreased wound infection from 23% to 4%.
• Mutagenicity. Increases the risk of developing cancer of the lung, oral cavity, kidney, urinary bladder, cervix, stomach, and uterus.
• Maternal/fetal heath. Increases the risk of infertility, abortions, ectopic pregnancy, premature rupture of membranes, and placenta previa and abruption. The risk of prematurity and low birth weight, still birth, and sudden infant death syndrome is higher in children born to smoking mothers compared to nonsmokers

Acute COPD exacerbation

Dependent on surgical procedure, intraoperative events, and the need for postoperative intubation and mechanical ventilation

• Oxygen therapy usually will be required in the PACU and occasionally on the nursing floor.
• Requirement of analgesics often will be higher due to increased metabolism of drugs and decreased pain threshold. Patient-controlled analgesia (PCA) is highly recommended. Regional, epidural, and field blocks should be considered, if appropriate.
• Breathing exercises, physical therapy, and incentive spirometry are mandatory.
• DVT prophylaxis
• Surveillance of wounds to facilitate early detection and treatment of wound infections
• Nicotine patches may be prescribed to prevent nicotine withdrawal. Nicotine patches are not known to increase wound infections.

Nicotine withdrawal, inadequate pain control, poor wound healing, DVT, PPC

• Chronic Bronchitis
• Oxygen-Carrying Capacity

305.1 Tobacco use disorder

Z72.0 Tobacco use

Jagan Devarajan , MD, FRCA

Beth H. Minzter , MD, MS, FIPP