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Smoking: Should I Quit for Surgery and Anesthesia?

INTRODUCTION
Patients that smoke are often told to quit, at least temporarily, when they face surgery and anesthesia. This is often the source of much anxiety for the patient, and much confusion on the part of nurses and doctors. Is it really beneficial to quit smoking for a short period of time? If so, how long does the patient actually have to abstain in order for there to be a benefit?

It should be clear that smoking is a health risk whether or not a patient is having surgery or anesthesia in the future. There are significant and well-documented risks that should motivate anyone to quit smoking whenever possible. This article is not intended to address the overall benefits of smoking cessation (of which there are many), but to look specifically at the issue of smoking and anesthesia. If an upcoming surgery and anesthetic provides motivation for a patient to quit smoking, that is a great reason to do it!

EFFECT OF SMOKING
Smoking does two things in terms of the cardiovascular system that anesthesiologists area concerned about. First, smoking increases the amount of carbon monoxide attached to hemoglobin in the blood. This has the effect of decreasing oxygen supply. Carbon monoxide also makes the heart pump more poorly, also decreasing the amount of oxygen that is delivered to the body. Second, nicotine increases the amount of oxygen that the body needs. So, oxygen supply is being compromised at the same time that more oxygen is being utilized.

Smoking obviously also affects the lungs. Among other thigns, smoking causes an increase in the amount of mucus secreted while at the same time decreasing the ability of the lungs to clear these secretions. In addition, smoking causes the small airways in the lungs to be narrowed and more prone to collapse. The end result of these effects are an increased susceptibility to infection, chronic cough and increased chance of pulmonary complications. Lastly, smokers also have increased sensitivity to stimuli and increased bronchial reactivity, increasing the chance for bronchospasm and other life threatening pulmonary processes.

This is not just theory. There have been multiple studies confirming that smoking increases the incidence of pulmonary complications after an anesthetic as much as six times. Smoking has been shown to be an independent risk factor for complications ranging from complications of lung function to wound healing to cardiovascular events such as heart attack.

SMOKING CESSATION
So what if a person stops smoking. Is there any benefit to doing so in terms of what happens with anesthesia? It seems that within 12-24 hours of smoking cessation, there is a significant decrease in the effects of carbon monoxide in the body and much of the nicotine that is in the bloodstream will have been eliminated. This should improve oxygen supply and reduce oxygen demand. This is a good thing from the cardiovascular standpoint!

Unfortunately, the picture is not so clear and simple. It seems to take at least 48 hours to begin to show an improvement in the increased sensitivity and increased bronchial reactivity that is seen in smokers. It probably takes as much as two weeks before these factors are improved as much as possible. So, just in terms of pulmonary effects, a short term cessation of smoking does not seem to make much of a difference.

In fact, a short term cessation may actually make things worse. It seems the effects of increased secretions, decreased ability to clear these secretions, small airway disease, etc. take as much as four to eight weeks to reverse. In fact, a couple of studies have shown that patients who quit smoking have an increased risk of pulmonary complications unless they have quit for four weeks or more. So while smokers may have more problems than nonsmokers, it seems that smokers that have recently quit actually do worse than those that keep smoking.

It is not completely clear why this is true. Some have theorized that the absence of smoke in these patients actually causes them to cough less and therefore clear their lungs less efficiently when they first quit. Since it takes a while before the natural defenses of the lung can regenerate, this initial period is a particularly "at risk" time for having surgery and anesthesia.

The good news is that patients who quit for more than four weeks do seem to have a decreased risk of complications. In addition, patients who are able to quit for ten weeks or more have their risk reduced to almost the same as patients that have never smoked. Smoking cessation is not futile - and should be encouraged in patients that have surgery and anesthesia scheduled more than a month in advance. The data is encouraging in that patients that indeed quit can reduce their risk to close to nonsmokers in as little as ten weeks. The motivation to decrease their risk for anesthesia may be the motivator that some patients need to quit for good. This is a positive step to take, not just for anesthesia, but for overall health and well-being.


 

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