1Peri-operative smoking control French Conference of Experts Peri-operative smoking control.

1Peri-operative smoking control

French Conference of Experts

Peri-operative smoking control


Background

Smoking consumption is the cause of a significant increase risk of surgical adverse events, too often neglected.

A good assumption of the responsibility of the tobacco smoke must lead to a quick benefit, reducing general and local surgical complication rate, which would constitute a significant profit in term of health and savings.


Gradation A, B, C, D or E of recommendations

Gradation des 143 recommandations

A3%

B4%

C6%

D28%E

59%

Most of the recommandations are

grade E

Recommandations level A are only 3%


6 questions

QS1: What are the tobacco related risks in surgical period?

QS2 What are the proven benefits from of quitting smoking during the surgical period?

QS3 How a smoker should be help before elective surgery?

QS4-What is the role of each health professionals in the surgical period?

Qs5- What are the specificities of an anesthesia for a smoker patient ?

QS 6: How to deal with dependent smoker hospitalized for a not anticipate surgical procedure?


Number of smokers amongsurgical patients in France

Daily smokers 13 millions

General ansethesia8 millions

Smokers With

surgery2

millions


Moller study : risk of ICU transfer after surgery

Prospective study on 6 026 patients General surgery and orthopedic surgery compare NS et S > 50 Py to ES or S< 50 Py or NS

Admission in ICU : significantly higher if patient had smoke > 50 Py (p<0.001).

Mortality : Non significant excess of mortality

after smoker admitted in ICU compare to non smoker 37% vs 24% (OR=2.02 ; 99CI = 0.92-4.41 ; p=0.08)

Moller AM, Pedersen T, Villebro N, Schnaberich A, Haas M, Tonnesen R. A study of the impact of long-term tobacco smoking on postoperative intensive care admission. Anaesthesia. 2003 Jan;58(1):55-9.


General surgery mortality study Delgado-Rodriguez

Prospective study 2 989 surgical patients

Increase admission in ICU if ≥ 51 Py (OR=2.86 ; 95 CI = 1.21-6.77).

Increase death at hospital if ≥ 51 Py (OR=2.56 ; 95 CI = 1.10-5.97).

Delgado-Rodriguez M, Medina-Cuadros M, Martinez-Gallego G, Gomez-Ortega A, Mariscal-Ortiz M, Palma-Perez S, Sillero-Arenas M. A prospective study of tobacco smoking as a predictor of complications in general surgery.Infect Control Hosp Epidemiol. 2003 Jan;24(1):37-43


Myles study on 489 surgical patients

Prospective study CO measurement to confirm smoking

status reported Record of all respiratory complications.

Myles PS, Iacono GA, Hunt JO, Fletcher H, Morris J, McIlroy D, Fritschi L. Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology. 2002 Oct;97(4):842-7.

complications respiratoires

25.9%

32.8%

0%

5%

10%

15%

20%

25%

30%

35%

non fumeur fumeur

Respiratory complications OR= 1.71; 95% IC, 1.03-2.84; p= 0.038


Schwilk study 26 961 surgical patients

Prospective study 26 961 patients (7122 =26.4% smokers)

COPD 23.3% (4.8% among smokers). 1573 complications in 1397 patients (5.2%) 1114 respiratory events

complications respiratoires

3.1%

5.5%

0%

1%

2%

3%

4%

5%

6%

non fumeur fumeur

Schwilk B, Bothner U, Schraag S, Georgieff M. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiol Scand. 1997 Mar;41(3):348-55.

RR of respiratory events• 1.8 in smokers• 2.3 in smokers 16-39 y old)• 6.3 in overweight young smokers

RR of bronchospasm : 25.7 in young smokers with COPD


Moller randomized study cardiovascular complications

120 smokers randomized 6-8 weeks before surgery

Nurse training every week + medications as need

No specific intervention

(p=0.08) Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

complications cardiovasculaires

0%

10%

0%

2%

4%

6%

8%

10%

12%

non fumeur fumeur


Moller randomized study all complications




(p=0,0003) Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

Toutes complications

18%

52%

0%

10%

20%

30%

40%

50%

60%

non fumeur fumeur


1.3 Which are the risks of general complications

(cardiovascular, respiratory, and infectious,…)?

The increase in the relative risk (RR) according to studies concerns:

The risk of being transferred to an intensive care units (RR from 2.02 to 2.86) [D],

Infectious complications (RR from 2 to 3.5) [D],

Coronary complications (RR of 3) [D], Immediate respiratory complications (RR of

1.71) [D].


Sorensen prospective study scar in healthy voluntaries

complications cicatrice

2%

12%

0%

2%

4%

6%

8%

10%

12%

14%

non fumeur fumeur

Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg. 2003 Jul;238(1):1-5.

•48 smokers 30 non smokers randomized.•Incisions in sacrum area (n= 228)•Smoke 20 cig / j 1 week then continue to smoke

Patch placebo patch active

NB: No difference between non smokers (patch or placebo ) no influence of nicotine.

P <0.05


Möller : Prospective randomized study on scar complications





complications cicatrice

5%

31%

0%

5%

10%

15%

20%

25%

30%

35%

non fumeur fumeur


Möller prospective randomized studyneed for second intervention





nécessité réintervention

4%

15%

0%2%4%6%8%

10%12%14%16%

non fumeur fumeur


Retrospective Padubidri study on 748 breast reconstructions

Necrosis of mastectomy scrap smokers 7,7 %Ex smokers 2,6 %Non smokers 1,5 %

(p < 0.001)

Padubidri AN, Yetman R, Browne E, Lucas A, Papay F, Larive B, Zins J. Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg. 2001 Feb;107(2):342-9.

Nécrose lambeau mammaire

2%3%

8%

0%

2%

4%

6%

8%

10%

non fumeur ex fumeur fumeur


Retrospective Möller study811 hip or knee prosthesis

232 smokers (28.6%) and 579 non-smokers

Smoking doubled the risk of prolonged hospitalization (> 15 days)

Complication of scarsmokers RR 3.2

Admission in ICUSmokers RR 8.5

Moller AM, Pedersen T, Villebro N, Munksgaard A. Effect of smoking on early complications after elective orthopaedic surgery. J Bone Joint Surg Br. 2003 Mar;85(2):178-81.


Willigendael Meta-analysis on vascular by-pass.

29 studies (4 randomized, 12 prospective and 13 retrospectives).

In randomized trial and prospective studies, the risk of by pass failure increase 3.09 (IC: 2.34-4.8 p< 0.0001) with smoking continuation.

No difference between venous and polyester by pass. Correlation between by pass permeability and intensity of

tobacco consumption.Quitting at surgery provide a permeability rate close to non

smoker rate. Continuation of smoking could be responsible of 57% of

failure (IC 95%, 50%-64%).Willigendael EM, Teijink JA, Bartelink ML, Peters RJ, Buller HR, Prins MH. Smoking and the patency of lower extremity bypass grafts: a meta-analysis. J Vasc Surg. 2005 Jul;42(1):67-74.


Willigendael meta-analysis on vascular by pass

Willigendael EM, Teijink JA, Bartelink ML, Peters RJ, Buller HR, Prins MH. Smoking and the patency of lower extremity bypass grafts: a meta-analysis. J Vasc Surg. 2005 Jul;42(1):67-74.

Prospective Studies

Retrospective studies


Prospective randomized Mollerstudy : days in hospital




Moller AM, Villebro N, Pedersen T, Tonnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.

Durée séjour hospitalier (j)

1113

0

5

10

15

non fumeur fumeur

(p < 0.01)

8-65 jours 7-55 jours


medico-economic outcome

If 10% of surgical patients benefit of the same outcome than in Möller study, the treatment of 200 000 smoker during preoperative period will save :

68 000 surgical complications (+ 34% of patients)

18 000 second intervention (+ 9% of patients)

400 000 days in hospital (+ 2 days per patient)

109 000 days un ICU(+ 0,545 day per patient)


QS 2

QS2 What are the proven benefits from of quitting

smoking during the surgical period?


2.1 What are the benefits of quitting smoking according to the period before the surgical procedure (> 48 hours)?

The surgical risk of former smokers for a long period is lower than the risk of current smokers and not different from those of non smokers [C].

Smoking cessation of 6-8 weeks before surgery diminishes the surgical risk observed in current smokers [A].

Smoking cessation closer to surgery, 3-4 weeks before, is beneficial for decreasing all the surgical risks [C].

Smoking cessation of less than 3 weeks before surgery is beneficial, as it reduces the local surgical site’s complications that counterbalance the potential increase risk of respiratory complications [E].


2.2 What are the benefits of smoking reduction with or without nicotine replacement therapy before surgical

procedure, according to the period (> 48 hours)?

Smoking reduction without nicotine replacement therapy is not to be recommended. [E].

One may anticipate a potential benefit of an observed decrease in the circulating CO, observed when smoking reduction is associated with nicotine replacement therapy [E].

There is a lack of evaluation of the smoking reduction under nicotinic replacement therapy during the surgical period [E].


2.1 Benefits to quit tobacco according to the delay before?

0 1 2 3 4 5 6 7 14 21 4 sem 6 sem 8 sem

Toux, sécrétions bronchiques

Infections respiratoires

Complications cicatrices

Estimation score total

Baisse HbCO

Hyper réactivité VADS


2.3 What are the benefits of late smoking cessation, with or without nicotine replacement therapy, in the 48 hours

preceding a surgical procedure

From the physiological point of view, complete smoking cessation even of less than 48 hours before surgical procedure should be beneficial [E].

Temporary increase in cough and bronchial secretions are the only related adverse events that can be harmful just after smoking cessation [E].


Rapid decrease of CO after smoking cessation

C0 ppm

0

10

20

30

40

50

60

0 h 6 h 12 h 18 h 24 h 30 h


Decrease of cardiac and respiratory risk in the 48 hours of quitting

score moyen de la toux lors de l'abstinence

0

0.2

0.4

0.6

0.8

1

Precessation 2 7 21

Jours d'abstinence tabagique

AbstinentsNon fumeurs

Yamashita S, Yamaguchi H, Sakaguchi M, Yamamoto S, Aoki K, Shiga Y, Hisajima Y. Effect of smoking on intraoperative sputum and postoperative pulmonary complication in minor surgical patients. Respir Med. 2004 Aug;98(8):760-6.

Cardiac risk decrease the day of quiting

Sputum production

increase initially


2.5 Does smoking cessation during the surgical period contribute to long term smoking cessation?

In the general population, the relapse rate after quitting is approximately 50% one year after cessation [A].

In the case of cardiac surgery, 50% of post coronary artery surgical patients who quit smoking had relapsed one year later [C].

Quitting smoking for a surgical procedure is a positive prognostic factor for long term smoking abstinence. However, the high relapse rate highlights the need to reinforce the prevention of relapses [E]


Ratner study : 237 smokers randomized for smoking cessation before elective surgery

Ratner PA, Johnson JL, Richardson CG, Bottorff JL, Moffat B, Mackay M, et al .Efficacy of a smoking-cessation intervention for elective-surgical patients. Res Nurs Health 2004; 27:148-61.

fumeurs100%

47%

31%

100%

27%20%

0%

10%

20%30%

40%

50%

60%

70%80%

90%

100%

à l'annonce del'intervention

à l'intervention 6 mois aprèsl'intervention

groupe intervention

groupe control


2.6 What are the benefits of continuous abstinence after surgery on bone consolidation and thrombosis

risk? When smoking abstinence is continued in the

postoperative period, the benefit on bone consolidation is demonstrated [D] and the benefit on skin and soft cicatrisation is probably beneficial [E].

When smoking cessation is maintained in the post operative period, benefits are seen in osseous consolidation [D], and probably in skin and soft cicatrisation [E].

The permeability of vascular bypass is improved, when smoking cessation is prolonged during the post operative period [A].

In smokers, thromboses of vascular bypass are 57% tobacco related [B].


QS 3

QS3 How a smoker should be looked after

before elective surgery?


Standard procedure for identification and treatment of smoker before surgery

Accéder à la procédure en Word ou pdf


Procedure for in patients

Accéder à la procédure en Word ou pdf


Conclusion

All surgical department has to be organized to identified smokers 6-8 weeks before surgery as soon as possible

All surgical department has to organize smoking cessation in preoperative period with adequate tools

All surgical department need to organize substitution of smoker during surgery

All surgical department had to organize follow up of formers smoker to prevent relapse

1Peri-operative smoking control French Conference of Experts Peri-operative smoking control.

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