Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation.

Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.

Utilizing Patient E-learning in an Intervention Study on Preoperative Smoking Cessation.

BACKGROUND: Patients who smoke put themselves at increased risk for serious surgical complications, yet it is not currently routine practice to educate patients about the risk of complications due to smoking. Computer-based smoking cessation programs are increasingly being utilized in the general population and may overcome some of the barriers such as lack of time, knowledge, and training to provide interventions. Our objective was to develop and implement a patient e-learning program designed for surgical patients as part of a multifaceted program aimed at assisting them to quit smoking and to determine the factors cross-sectionally and longitudinally associated with abstinence. METHODS: In this prospective multicenter study, smokers undergoing elective noncardiac surgery participated in a preoperative smoking cessation program consisting of a patient e-learning program, brief advice, educational pamphlet, tobacco quitline referral, letter to the primary care physician, and pharmacotherapy. The patient e-learning program described (1) the benefits of quitting smoking before surgery; (2) how to quit smoking; and (3) how to cope while quitting. The 7-day point prevalence (PP) abstinence on the day of surgery and at 1, 3 and 6 six months after surgery was separately assessed, and factors most associated with abstinence were identified using multivariable logistic regression analysis. Generalized estimating equation methods were used to estimate effect of the factors associated with abstinence longitudinally. The reach of the program was assessed with the number of smokers who participated in the program versus the number of patients who were referred to the program. RESULTS: A total of 459 patients (68.9% of eligible patients) participated. The 7-day PP abstinence at day of surgery, 1 month, 3 months, and 6 months was 22%, 29%, 25%, and 22%, respectively. The variables predicting abstinence at 6 months were use of pharmacotherapy (odds ratio [OR], 7.32; 95% confidence interval [CI], 3.71-14.44; P < .0001) and number of contacts with a tobacco quitline (OR, 1.60; 95% CI, 1.35-1.90; P < .0001). Presence of other smokers in the household (OR, 0.39; 95% CI, 0.21-0.72; P = .0030) and amount spent on cigarettes weekly at baseline (per $10 increase) (OR, 0.73; 95% CI, 0.61-0.87; P = .0004) were barriers to abstinence. CONCLUSIONS: Our preoperative smoking cessation program resulted in a 7-day PP abstinence of 22% at 6 months. A multifaceted intervention including a patient e-learning program may be a valuable tool to overcome some of the barriers to help surgical patients quit smoking.

Obesity hypoventilation syndrome, sleep apnea, overlap syndrome: perioperative management to prevent complications.

PURPOSE OF REVIEW: The prevalence of sleep disordered breathing (SDB) is increasing proportional to the prevalence of obesity. Although anesthesiologists are familiar with obstructive sleep apnea (OSA) - the most common SDB, anesthesiologists may not be aware of other SDB such as obesity hypoventilation syndrome (OHS) and overlap syndrome (combination of OSA and chronic obstructive pulmonary disease). The present review provides an update of information regarding the perioperative management of OHS and overlap syndrome. RECENT FINDINGS: OHS and overlap syndrome are associated with significant comorbid conditions and more perioperative morbidity than OSA alone. Similar to OSA, most of the OHS patients are undiagnosed. An increase in serum bicarbonate level is a surrogate marker of hypercapnia. Because 90% of OHS patients have OSA, preoperative screening for OSA combined with estimation of serum bicarbonate level may detect the majority of the patients with OHS. In patients with OSA, OHS, and overlap syndrome, improvement in the perioperative outcome has been shown by initiating positive airway pressure therapy. SUMMARY: Identification and preoperative optimization of these high-risk patients are most important. A protocol-based risk mitigation is necessary for improving the intraoperative and postoperative outcome of these patients. As a perioperative physician, anesthesiologists have a key role in the management of patients with SDB.

Perioperative consideration of obstructive sleep apnea in ambulatory surgery.

The prevalence of obstructive sleep apnea (OSA) is increasing and a significant number of patients with OSA are undiagnosed. The suitability of ambulatory surgery in patients with OSA remains controversial, and the evidence regarding the safety of ambulatory surgery for patients with OSA is limited. Preoperative screening and careful selection of patients for ambulatory surgery is the most important step. Patients diagnosed and suspected of having OSA should be managed with a systematic algorithm to improve outcomes.

New supraglottic airway with built-in pressure indicator decreases postoperative pharyngolaryngeal symptoms: a randomized controlled trial.

PURPOSE: Excessive supraglottic airway cuff pressure increases postoperative pharyngolaryngeal symptoms such as sore throat, dysphonia, and dysphagia. A new supraglottic airway, AES Ultra CPV™ (CPV), has a built-in intracuff pressure indicator. We hypothesized that using the CPV would reduce postoperative symptoms when compared with the LMA Classic™ (LMA) without intracuff pressure guidance. METHODS: Ambulatory patients undergoing general anesthesia were randomized to either CPV or LMA. A size 3/4/5 was inserted according to manufacturer guidelines. Nitrous oxide was not used. In the LMA Group, the cuff was inflated according to manufacturer's guidelines. In the CPV Group, a CPV was inserted and the cuff inflated until the indicator was in the green zone (30-44 mmHg). Intracuff pressures were measured at five minutes and 20 min post-insertion in both groups. The primary outcome was the incidence of pharyngolaryngeal symptoms, defined as sore throat, dysphonia, and/or dysphagia at one, two, and/or 24 hr postoperatively. Continuous data were compared using Student's t test and categorical data were analyzed using Chi square analysis. RESULTS: The study included 170 patients, 85 per group. The mean (SD) intracuff pressure in the CPV group was significantly lower [44 (4) mmHg] than in the LMA Group [87 (37) mmHg]; P < 0.001. The incidence of pharyngolaryngeal symptoms was significantly lower in the CPV Group than in the LMA Group (26% vs 49%; P = 0.002). The absolute risk reduction was 24%, and the number-needed-to-treat was 4.3. CONCLUSION: The incidence of postoperative pharyngolaryngeal symptoms in the CPV Group with a cuff pressure-guided strategy was significantly lower than in the LMA Group with standard practice. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT01800344).