Smoking and Perioperative Outcomes

Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
Anesthesiology (Impact Factor: 5.88). 03/2011; 114(4):837-46. DOI: 10.1097/ALN.0b013e318210f560
Source: PubMed


Patients are often concerned about the effects of smoking on perioperative risk. However, effective advice may be limited by the paucity of information about smoking and perioperative risk. Thus, our goal was to determine the effect of smoking on 30-day postoperative outcomes in noncardiac surgical patients.
We evaluated 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database; 520,242 patients met our inclusion criteria. Of these patients, 103,795 were current smokers; 82,304 of the current smokers were propensity matched with 82,304 never-smoker controls. Matched current smokers and never-smokers were compared on major and minor composite morbidity outcomes and respective individual outcomes.
Current smokers were 1.38 (95% CI, 1.11-1.72) times more likely to die than never smokers. Current smokers also had significantly greater odds of pneumonia (odds ratio [OR], 2.09; 95% CI, 1.80-2.43), unplanned intubation (OR, 1.87; 95% CI, 1.58-2.21), and mechanical ventilation (OR, 1.53; 95% CI, 1.31-1.79). Current smokers were significantly more likely to experience a cardiac arrest (OR, 1.57; 95% CI, 1.10-2.25), myocardial infarction (OR, 1.80; 95% CI, 1.11-2.92), and stroke (OR, 1.73; 95% CI, 1.18-2.53). Current smokers also had significantly higher odds of having superficial (OR, 1.30; 95% CI, 1.20-1.42) and deep (OR, 1.42; 95% CI, 1.21-1.68) incisional infections, sepsis (OR, 1.30; 95% CI, 1.15-1.46), organ space infections (OR, 1.38; 95% CI, 1.20-1.60), and septic shock (OR, 1.55; 95% CI, 1.29-1.87).
Our analysis indicates that smoking is associated with a higher likelihood of 30-day mortality and serious postoperative complications. Quantification of increased likelihood of 30-day mortality and a broad range of serious smoking-related complications may enhance the clinician's ability to motivate smoking cessation in surgical patients.

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    • "Smoking is known to be associated not only with many chronic diseases, but also with substantial burdens on healthcare systems worldwide [1]. Furthermore, it is well established that smoking has a negative effect on postoperative outcome for patients undergoing surgical procedures including a higher likelihood of 30 day mortality and serious postoperative complications [1] [2]. Smokers are also at greater risk of postoperative wound healing disturbances compared to nonsmokers [3]. "
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    ABSTRACT: Background It is well established that smoking has a myriad of negative effects on varies aspects of bodily health. The aim of this study was to examine the effects of the smoking status at time of surgery on the postoperative subjective pain course and health related quality of life (HRQoL) until 1 year after surgery for lumbar disc herniation (LDH). Method This prospective cohort study included patients ≥18 and ≤90 years of age with a symptomatic and radiological verified LDH. The current smoking patient collective (smoking 1 or more cigarettes a day) was compared with the nonsmoking collective (previous smokers without cigarette consumption for >2 months and never smokers) in respect of subjective pain sensation (measured with the visual analogue scale (VAS)) and HRQoL using the short-form (SF-12) questionnaire preoperatively, before discharge, as well as after 4 weeks and 1 year postoperatively. The primary outcome measures were the 1-year SF-12 scores (MCS and PCS) categorized into responders and non-responders. Results A total of 102 patients were enrolled in the study. Thirty-eight patients were current smokers (37.2%), whereas 43 (42.2%) and 21 (20.6%) patients were never-smokers and previous smokers, respectively. Four weeks and one year after surgery, both smokers and nonsmokers reported increase in the HRQoL as compared to preoperative values – the MCS increased more than the PCS. From a univariate and multivariate perspective, smoking status at time of surgery did not predict responder status. Conclusions The present study results could not confirm the hypothesis that smoking at time of surgery was associated with worse outcome after surgery for LDH.
    Clinical Neurology and Neurosurgery 07/2014; 122:12–19. DOI:10.1016/j.clineuro.2014.04.015 · 1.13 Impact Factor
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    • "In order to minimise the impact of the potentially unequal distribution of confounding factors between groups, adjustments for the different risk profiles of patients should be made in analyses. Smoking is one of the most important factors to include in risk adjustment because it is so influential in terms of health [1]–[3], and its prevalence varies between groups within populations [4], [5]. With the exception of perinatal data collections, which capture information about smoking during pregnancy, Australian administrative hospital datasets do not contain specific items relating to smoking status. "
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    ABSTRACT: Adjustment for the differing risk profiles of patients is essential to the use of administrative hospital data for epidemiological research. Smoking is an important factor to include in such adjustments, but the accuracy of the diagnostic codes denoting smoking in hospital records is unknown. The aims of this study were to measure the validity of current smoking and ever smoked status identified from diagnoses in hospital records using a range of algorithms, relative to self-reported smoking status; and to examine whether the misclassification of smoking identified through hospital data is differential or non-differential with respect to common exposures and outcomes. Data from the baseline questionnaire of the 45 and Up Study, completed by 267,153 residents of New South Wales (NSW), Australia, aged 45 years and older, were linked to the NSW Admitted Patient Data Collection. Patients who had been admitted to hospital for an overnight stay between 1 July 2005 and the date of completion of the questionnaire (1 January 2006 to 2 March 2009) were included. Smokers were identified by applying a range of algorithms to hospital admission histories, and compared against self-reported smoking in the questionnaire ('gold standard'). Sensitivities for current smoking ranged from 59% to 84%, while specificities were 94% to 98%. Sensitivities for ever smoked ranged from 45% to 74% and specificities were 93% to 97%. For the majority of algorithms, sensitivities and/or specificities differed significantly according to principal diagnosis, number of comorbidities, socioeconomic status, residential remoteness, Indigenous status, 28 day readmission and 365 day mortality. The identification of smoking through diagnoses in hospital data results in differential misclassification. Risk adjustment based on smoking identified from these data will yield potentially misleading results. Systematic capture of information about smoking in hospital records using a mandatory item would increase the utility of administrative data for epidemiological research.
    PLoS ONE 04/2014; 9(4):e95029. DOI:10.1371/journal.pone.0095029 · 3.23 Impact Factor
    • "Compared with never-smokers, former and current smokers have a 10%–40% increased risk of 30-day mortality after noncardiac surgery (Hawn et al., 2011). Current smokers have up to a threefold increase in the risks of surgical site infection, myocardial infarction, stroke, unplanned intubation, and prolonged mechanical ventilation than nonsmokers (Hawn et al., 2011; Turan et al., 2011). Compared with never-smokers, current smokers are twice as likely to be admitted to an intensive care unit after general and orthopedic surgery (Moller, Maaloe, & Pedersen, 2001). "
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    ABSTRACT: Introduction: Smoking is a preventable cause of perioperative complications. An accurate and rapid classification of smoking status is essential as up to 35% of smokers deny smoking before surgery. We compared the diagnostic performance of a preoperative urinary cotinine immunoassay test strip (NicAlert®) as an add-on test to patient's self-reported smoking status. Methods: Four hundred and sixty-five patients undergoing major elective surgery self-reported their smoking history and provided a sample for measuring urinary cotinine concentration by liquid chromatography tandem mass spectrometry (reference standard) and NicAlert®. Using the "either test positive" rule, the gain in diagnostic performance for NicAlert® add-on test was assessed using relative positive and negative likelihood ratios (LRs) and area under the receiver operating characteristic curve (AUROC) with 95% CIs. Results: Of the 60 patients with a positive reference standard (adjusted cotinine ≥ 50 ng/ml), 10 (16.7%) denied current cigarette smoking. The NicAlert® add-on test had better test performance measures (sensitivity = 95.0%, specificity = 94.8%) than self-reported smoking history alone (sensitivity = 83.3%, specificity = 95.0%). The relative positive and negative LRs were 1.09 (95% CI = 0.95-1.24) and 0.30 (95% CI = 0.12-0.78), respectively. The AUROC for the NicAlert® add-on test (0.90; 95% CI = 0.84-0.96) was significantly higher than for the self-reported smoking history alone (0.78; 95% CI = 0.69-0.88) (p = .006). Conclusion: The NicAlert® add-on test strategy had excellent diagnostic test performance for identifying current smokers who are expected to have a high risk of perioperative complications.
    Nicotine & Tobacco Research 03/2013; 15(10). DOI:10.1093/ntr/ntt039 · 3.30 Impact Factor
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