Improving Smoking Cessation Activities in the Preoperative Phase for Safer Cardiac Anaesthesia and Better Surgical Outcomes

Cardiac anaesthesia plays a significant role in managing all cardiovascular surgeries and ensures that patients remain hemodynamically stable, pain-free, and provides adequate oxygen supply during these complicated procedures. This is accomplished by preventing pain and discomfort during the procedure, controlling the vital parameters, managing comorbidities, reducing the trigger to a massive stress response, and facilitating cardiac monitoring, which is crucial in the recovery of the patients.[1,2] This minimizes the risk of the development of complications. Also, it aids surgeons in performing complex procedures by maintaining the functions of various organs during surgery. Even upon the completion of the surgery, the anaesthesiologist plays a crucial part in ensuring the recovery of the patient, and thus it is an integral part of modern cardiovascular surgery and a safe possible outcome. Impact of Smoking on Cardiac Anaesthesia Smoking has a major influence on cardiac anaesthesia and subsequently can augment the risks attributed to cardiovascular surgeries.[3] This is predominantly because it decreases the ability of the body to carry oxygen efficiently, and these reduced oxygen levels can account for complications during surgery, delaying the process of recovery post-surgery. Smoking accounts for increased mucus production in the lungs (reactive airways), which can obstruct airways during and after anaesthesia, which results in breathing difficulties and a heightened risk of lung infections. Moreover, a higher incidence of anaesthesia-related complications (viz. airway spasm, deranged heart rhythms, blood pressure fluctuation, etc.) has been reported among smokers undergoing cardiovascular surgeries.[3] Smoking patients who have undergone cardiovascular surgeries tend to have prolonged stays in intensive cardiac units and hospitals, amounting to higher out-of-pocket expenditures.[4] Role of Smoking Cessation in Preoperative Care for Cardiac Surgery Acknowledging the consequences of smoking on anaesthesia in general and cardiac in particular, smoking cessation before cardiac surgery has been strongly recommended.[5] In-fact, a patient who has not smoked for a few weeks before cardiovascular surgery tends to fare better during surgery and in the recovery period because of the improvement in the functions of the heart and lungs.[6] A person who quits smoking before undergoing cardiovascular surgery tends to have improved oxygen levels in the blood, lung functions become better, stabilization of heart rate and blood pressure, improvement in blood circulation, reduced mucus production, and better wound healing, all of which contribute to an uneventful surgery and quick recovery.[5,6] Further smoking cessation improves the immune system and helps the body to effectively fight against infections, which is vital after cardiovascular surgery. Moreover, this smoking cessation accounts for long-term benefits to the heart, thereby reducing the probability of occurrence of future cardiovascular events. Barriers to Preoperative Smoking Cessation Despite being aware that smoking cessation during the preoperative period can remarkably improve surgery outcomes, the barriers to preoperative smoking cessation can be classified into three broad categories, namely patient-related, system-related, and healthcare provider-related, making it extremely challenging for cardiac patients. At the patient level, many cardiac patients have a strong nicotine dependence, and considering the stress of upcoming surgery, it becomes even more difficult.[7] The most important barrier on the patient’s behalf is the lack of willpower and motivation to quit smoking. In addition, patients who lack friends or family members who can support their decision to quit smoking, find it difficult as they lack all encouragement.[8] Another concern is when there is not much time left between when the diagnosis has been made and when surgery must be performed, and this lack of time does not allow patients to effectively quit smoking. Moreover, due to additional commitments and limited time during the preoperative period, adequate emphasis has not been given to smoking cessation.[7] In addition, most insurance companies do not cover smoking cessation therapies, and this financial burden acts as a major barrier for patients who could immensely benefit from quitting before they undergo cardiovascular surgery.[6,7] The last set of challenges is that not all healthcare providers are trained in counselling on smoking cessation, which makes it difficult to guide patients.[7] Strategies for Implementing Smoking Cessation The implementation of smoking cessation strategies during the preoperative period for patients who are due for cardiac anaesthesia can remarkably improve surgical outcomes by reducing the rates of complications.[5,6] This could be executed by including screening for smoking as a routine part of all preoperative assessments, and this will aid not only in the early identification of smokers but will even give more time for smoking cessation intervention.[5] Upon the identification of smokers, they should be educated about the risks associated with smoking during cardiac surgeries and the implications of smoking cessation on positive surgical outcomes.[5,6] This same period of counselling should also be used to identify reasons for quitting and accordingly build a plan to quit smoking.[3,8] These smokers can be either initiated on nicotine replacement therapy to manage withdrawal and reduce cravings, or started on prescription medications (these drugs can reduce the urge to smoke, like Varenicline or Bupropion for reducing cravings and the pleasurable effects of smoking).[9] A welcome approach will be to simultaneously run a smoking cessation program in the preoperative clinics itself, which can act as a single point of contact for resources, guidance, and follow-up provisions. To support the patients in quitting smoking, it is a good approach to involve a team of healthcare providers from different disciplines, encouraging patients from different angles. The progress in quitting smoking can be checked either via periodic follow-up visits or telehealth consultations to make it feasible and easy for patients. Some educational materials in the language, which patients understand can be given, as they can be a constant source of motivation.[9,10] In conclusion, smoking cessation proves to be extremely beneficial for patients who are about to receive cardiac anaesthesia for their cardiovascular surgeries. The implementation of smoking cessation programs in the preoperative period can be done by the adoption of a multipronged approach that can target barriers at each level and thereby augment the outcomes for cardiac surgery patients. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.