1. Smoking and anaesthesia
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab. DCA, Dip. Software statistics- Phd(physio)
Mahatma Gandhi Medical college and research institute , puducherry , India

2. history Morton said in 1890 s
Smoking can cause postoperative pulmonary complications
A general surgeon in 1944 – proved it after fifty years

3. What is it ??
Smoke is an heterogenous aerosol produced by the incomplete combustion of the tobacco leaf
21 % incidence
One third smoke !!
What does it contain ??
Smoke
Gas particulate

4. 80% to 90% gaseous nitrogen, oxygen,and carbon dioxide.
carcinogens hydrocyanic acid and hydrazine, ciliotoxins,
irritants such as hydrocyanic acid, acetaldehyde, ammonia, acrolein, and formaldehyde,
and an agent impairing oxygen transport, namely carbon monoxide.

5. 10 -20 % - Particulate nicotine.
It also contains carcinogens such as tar and polynuclear aromatic hydrocarbons and tumor accelerators such as indole and carbazole.

6. Important for anaesthetists
Gaseous – carbonmonoxide
Particulate – nicotine

7. No mention about marijuana !!!
Why should we discuss smoking and anaesthesia ??

8. Established !! increased respiratory complications during and after GA
Surgical wound complication rates are higher in smokers, particularly following plastic and reconstructive surgery, bone surgery, bowel surgery and microsurgery.
Smoking has adverse effects on the blood flow to tissues that may impair wound healing
More ICU admissions
Delayed discharges

9. Generally problematic ??
Why should we bother ??
Generally problematic ??
Then stop !!

10. Other facts if you stop?? Adding six to eight years to your life.
Reducing your risk of lung cancer and heart disease.
Reducing your loved ones’ exposure to second-hand smoke.
Saving an average of Rs. _______ each year.
Can purchase a few plots

11. Smoking on systems - Cardiovascular system
Theft
higher oxygen consumption through the sympathetic- adrenergic system activation.
At the same time, there is decreased oxygen supply by increased COHb levels
coronary vascular resistance increase
risk factor for arterial thromboembolism and coronary vasospasm

12. On CVS – continued Resting catecholamine increase CO – hypoxemia
Negative inotropy
Increased viscosity
Myocardial ischemia

13. CVS Nicotine – two phases of actions Initial stimulation CVS
Ganglion blocking action – hypotension and neuromuscular paralysis

14. Respiratory system Increase mucus secretions.
Decreased ciliary activity
Laryngeal and bronchial reactivity is increased
small-airway narrowing, causing an increased closing volume.
Pulmonary surfactant is also decreased.
Loss of elastic recoil – COPD
FEV1 decrease 60 ml/year /// 20 ml/year
Infections !!

15. Respiratory system
Carboxyhaemoglobin levels maybe up to 15% in smokers.
the affinity of carbon monoxide to Hb is 250 times greater than oxygen.
This results in a reduction in the availability of oxygen binding sites and a reduction in oxygen carrying capacity.
Left shift of the oxygen haemoglobin dissociation curve results in reduced oxygen delivery to the tissues.
Bedside pulse oximeters -- Yes but no ?? !!

16. Smoking by virtue of mechanics and chemistry – prone for hypoxemia
The same is true for anaesthesia
Don’t add problems

17. Following smoking cessation
ciliary activity starts to recover within 4-6 days.
The sputum volume takes 2-6 weeks to return to normal.
There is some improvement in tracheo bronchial clearance after 3 months.
It takes 5-10 days for laryngeal and bronchial reactivity to settle.

18. But in simple terms
Long term smokers – pulmonary dysfunction and hypoxemia
Short term smokers -- reactive airway disease – spasm and hypoxemia
Passive smokers also !!

19. See there !!
Nicotine reaches the brain within seconds after inhalation.
Long term tobacco smoking of more than fifty pack years carries a higher risk of post-operative admission to intensive care .
The number of pack years is calculated by the number of packs smoked per day multiplied by the number of years smoked.

20. Bad things are short !!
Short abstinence periods may influence results due to the relatively
short nicotine (30 to 60 minutes)
COHb (4 hours) elimination half-life.

21. Other systems
Impaired humoral activity and cell mediated immunity leads to impaired immune response which results in increased risk of infection and malignancy.
It also decreases immunoglobulins and leucocyte activity.
Smoking also results in increased secretion of anti-diuretic hormone (ADH) leading to dilutional hyponatremia.

22. Other systems CNS stimulator Tobacco foetal syndrome
Paediatrics – wheezing episodes

23. Preop work up
Patients are advised to quit smoking at least four to six weeks prior to surgery.
Abstinence for twelve hours is sufficient to get rid of carbon monoxide.
Ciliary function improves and nicotine levels return to normal within hours.
Abstinence for 2 weeks helps return sputum volume to normal levels.
Laryngeal and bronchial activity is better in 5-10 days.
Improvement in small airway narrowing is seen in 4 weeks but it takes 3 months to see changes in tracheobronchial clearance.

24. But treat anxiety due to smoke withdrawal

25. Move on to anaesthesia

26. Preoperative objectives are based on
secretions control,
pulmonary function improvement
stopping smoking several weeks before surgery

27. Stopping Smoking * Ideally, stop smoking for at least 8 weeks prior to
surgery.
* Stop for 24 hours before surgery to negate effects of nicotine and COHb.
* If an operation is scheduled for the next morning,
stop smoking the previous evening.

28. Keep preoperative disclosures confidential

29. Preparation * Treat lung infections such as chronic bronchitis.
* Prescribe bronchodilators, breathing exercises,
chest physiotherapy in symptomatic smokers.
* Do blood gases to get baseline PaO2 and PaCO2 if a long operation is planned.

30. Underlying ischaemic heart disease and hypertension should be identified, and anaesthesia administered to minimize the risk from these factors.
Routine investigations
CxR, ECG, ECHO (SOS) PFT

31. Always consider
Regional or local
Even in spinal

32. THE EFFECT ON RESPIRATORY FUNCTION DURING SPINAL ANESTHESIA
FEV1 decreased – spinal above T10.
Forced mid expiratory flow decreased
Accumulation of secretions
Deep breath and cough during block !!

34. Drugs – enzyme induction
smokers have increased requirements for opioids postoperatively.
In a study of morphine requirements after cholecystectomy, Glasson et al. found that smoking significantly influenced the requirement for pethidine and morphine
Increased fentanyl and increased complications
Cause ?

35. Possible causes Administer more analgesics, needed due to
i) anxiety from stopping smoking,
(ii) decreased pain threshold,
(iii) increased metabolism of the drug.

36. Drugs NSAIDs and paracetomol --- no effect
smoking decreases the potency of aminosteroid muscle relaxants ??
Atracurium also affected
Relevance ??
Scoline - ??
Rocuronium !!
Nicotine -- down regulates NMJ receptors ?!

37. Drugs P450 induction , drugs and decreased PONV Theophylline ,
ropivacaine !!,
enflurane and flouride levels
Alcohol and cigarette smoke

38. Anaesthesia Preoxygenation IV induction – smooth
IV lignocaine – smooth intubation
Halo or sevo
rocuronium
No manipulation under light anaesthesia
Increase MV to maintain ETCO2
No desflurane

39. Monitors Routine ECG ABG – PaCo2 -- ETCO2 – difference higher
NMJ monitors

40. Recovery
Extubate with adequate narcotics to prevent spasm episodes

41. Should I quit smoking permanently??
Yes -- better
50 % Vs 20 % complications if continued

42. increased blood viscosity and risk of postoperative deep venous thrombosis
Some advocate
Bupropion in the post op period as
Nicotine replacement therapy

43. Epidural if there – continue
Appropriate analgesia should be prescribed, particularly for abdominal or thoracic surgery where regional techniques such as epidural analgesia may have a role.
Early mobilisation is important to improve lung function and sputum clearance.
CHEST PHYSIOTHERAPY

44. Quitting causes cough ??
There is some misinformation with regard to deciding to quit smoking right before surgery.
There is no data to support the contention that quitting too close to surgery may cause additional coughing.
There also is no evidence of any other negative effects of quitting too close to surgery.

45. Proved compliance for anaesthesiologist s advice

46. Summary Heterogenous aerosol CO and nicotine
Pulmonary , wound healing, ICU admissions
Quit , anxiolytics, premed, prepare
Regional, local then GA , intubation
Deep – IV lignocaine, P450, narcotics, relaxants
Increased MV , no desflurane
Extubate without spasm
Post op oxygen, physiotherapy , epidural ,

47. Thank you all
Patients are compliant to us !!