2015 REPLACEMENT LECTURE NOTES

Which of these account for half of

perioperative mortality?
- Pulmonary
- Cardiac
- Haematologic
- Endocrine
- Thromboembolism prophylaxis
= Pulmonary
- due to hypoventilation > pneumonia >
atelectasis
- Occurs in about 1/3 of patients
Who are at risk of pulmonary complications
in perioperative situation?
1. smokers
2. COPD
3. Obesity
4. Old people
5. Thoracic surgery and upper abdominal
surgery
6. Anaesthesia for over 2 hours
What is done to assess pulmonary risk in
patients before operation?
1. FEV1 >2L = safe
2. Smoking have they quit and for how long
3. Bronchodilator therapy
4. Treatment of bronchitis
5. Mobilization
What complications does smoking cause
during anaesthesia?
1. Cardiac = ischaemia or arryhtmia
2. Vascular event = TIA or stroke
3. Respiratory = COPD emphysema
What complication does smoking cause
AFTER surgery
Similar to preoperative cardiac and vascular
events (strokes due to atherosclerosis)
+
Broncho pulmonary infection due to poor sputum
clearance pneumonia 6X increase in smokers
Describe the mechanisms of how smoking
increases wound infection?
Poor microcirculation
(vasoconstriction/atherosclerosis) reduced
oxygen content and delivery local thrombosis
(nitcotine increases platelet adhesiveness and
vasoconstriction) reduced collagen production
How long should patients stop smoking to
improve pulmonary complications in
surgery?
- 6 weeks can reduced pulmonary infection
- 6 months similar to those who havnt
smoked

Lecture 18 Anaesthetics
Effects of nicotine
1. Increased sympathetic activity
2. Increased heart rate and blood pressure
3. Peripheral vasoconstriction
Carbon monoxide (>10% in smokers)
- Decrease oxygen content
- Shift oxygen dissociation curve to the left
(impedes release of oxygen to tissues)
- Inhibit cytochrome C oxidase impair
mitochondrial function
Arteriosclerosis & Atherosclerosis
- Nicotine affects fatty acids in blood Blood
cholesterol levels
- Plaque builds up inside walls of blood
vessels = clog the blood vessels
- Smoking also constricts arteries =
arteriosclerosis (hardening of arteries)
- Risk of heart attacks or strokes
Heart attack
- 2X the risk
- Heart is damaged by a sudden lack of
blood flow = heart attack
o Heart muscles narrowed or blocked
Peripheral Vascular disease
- Caused by gradual narrowing of arteries in
arms of legs
- Atherosclerosis in tiny arteries
- Painful cramping during exercise,
numbness and tingling, weakness
- Risk of infection + amputation
- Similiarly the arteries that narrowing can
cause impotentce, wrinkles and dental
problems
Emphysema
- Damage to delicate air sacs = loss of
ability to exchange air
- Cigarette smoke most common cause of
this disease
- Tar in cigarette smoke cause irritation and
reduce elasticity in alveoli = lungs lose
ability to transfer oxygen to blood stream
Risk in anaesthesia
Medical complications
- Cardiac = Ischaemia/arrhythmia
- Vascular events = TIA/stroke
- Respiratory = COPD, emphysema
Postoperative complications
Cardiac = myocardial ischaemia/infarction
Bronchopulmonary infection = due to sputum
retention, pneumonia 6X more in smokers
Strokes = atherosclerosis
Wound infection
- Poor microcirculation (vasoconstriction or
atherosclerosis

O2
Thrombosis (nicotine platelet
adhesiveness and vasoconstriction)
Impairs cellular enzymes for mitochondrial
oxidative phosphorylation
Collagen production reduced

Bone healing joint replacement surgery

- Wound infection Joint infection
- Infected prosthetic joints never heal
properly
o Long term antibiotics
o Secondary surgery = complications
Nicotine replacement therapy
1. Patch
2. Adjuvant drugs
3. Varenicline = acetylcholine receptor partial
agonist

Pre-operative assessment and management

1. Patient factors (lung function, sputum,
current smoking status, hypoxia and
hypercapnia)
2. Comorbidities cardiac, cognitive
disturbance, mobility
Management = ceasing smoking reduces
pulmonary complications
6-8 weeks (4 weeks minimum) before surgery
reduces complication rates significantly
- Physiotherapy with bronchodilator
o Clears bronchial secretion
o Improve ventilation (poor
ventilation can risk collapse during
surgery)
- Choice of anaesthesia (local vs general)
- Minimise intra-operative atelectasis during
GA
- Pain control