Tell patients not to smoke for 24 hours, study says
Are you asking your patients not to smoke the morning of surgery and thinking that’s sufficient? Or perhaps you don’t mention smoking at all. A recent study will challenge your thinking.
The study showed that patients who smoked during the 24 hours before outpatient surgery with general anesthesia were more than 20 times more likely to have episodes of inadequate oxygen supply to the heart than nonsmokers, ex-smokers, and even smokers who abstained from smoking during the same period. The study of 500 patients was presented at the annual meeting of the Park Ridge, IL-based American Society of Anesthesiologists.
"Many patients smoke before surgery, especially when they know they can’t eat," says Harvey J. Woehlck, MD, associate professor of anesthesiology at the Medical College of Wisconsin in Mil-waukee and one of the researchers. "Perhaps more people would abstain if they knew it might be harmful." The carbon monoxide in cigarette smoke enters the bloodstream quickly and slows the delivery of oxygen. "This study basically was identifying that patients will have this abnormal heart activity, which we interpret of myocardial ischemia or not enough oxygen to the heart," he says.
Patients who smoked during the 24 hours before surgery and therefore had the highest levels of carbon monoxide in their blood during surgery were most likely to have brief episodes of myocardial ischemia. But smokers who did not smoke during the same time fame were virtually indistinguishable from nonsmokers and former smokers.
The researchers looked only at patients whose heart rates and blood pressure levels indicated they were experiencing at least moderate stress in response to surgery. Patients studied had otherwise healthy hearts with no symptoms of heart disease. And that raises a critical question for Woehlck: "If healthy smokers exhibit abnormal heart activity, what might we see in an older person with heart disease who smokes several cigarettes in the car on the way to the hospital?
"Healthy young people probably can survive with no further complications, just because they’re young and healthy and have lots of [oxygen] reserve. But older patients who have heart disease and other medical problems may find a bigger risk of having problems than young healthy patients, and we may find they have more complications." More study is needed in this area, Woehlck says. "Causing heart problems in young healthy person shows this is powerful poison. We can only imagine what can happen in older patients."
So what’s the bottom line? Tell all of your patients not to smoke at least one day before general anesthesia, Woehlck advises.
Discuss the issue, even if the patient is a chain smoker, says Lois Connolly, MD, clinical director of the department of anesthesia at Froedtert Memor-ial Lutheran Hospital, West Campus, in Milwau-kee. Connolly was part of the research group. "It might not [currently] be stressed that an important aspect of pre-op care is to at least cut down on smoking, if not quit, the day before surgery."
Emphasize these instructions by presenting them in writing and verbally, Woehlck suggests. "If it’s something that only appears in fine print in long list of instructions, chances are most people aren’t going to do it. It’s most important to tell people: "Don’t eat before surgery". So people get that in writing and are told that. It may be important to do that for avoiding smoking. The more times people are told to do or not to do that, the most likely people are to feel it’s important."
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