Preoperative Lifestyle

Alcohol

Managing excessive alcohol consumption presents a genuine challenge to perioperative teams aiming to effectively prehabilitate patients in the lead up to major surgery. Whilst chronic alcoholism remains a leading international public health concern, lesser levels of consumption also appear to confer an increased risk of poor postoperative outcome.

System	Effect of elevated alcohol intake
Immunological	Impaired wound healing. Supressed delayed-type hypersensitivity
Cardiovascular	Subclinical cardiac insufficiency Increased risk of perioperative haemorhage
Haematological	Coagulopathy and increased perioperative haemoorhage
Gastrointestinal	Disordered hepatic handling of drugs
Endocrine	Accentuated endocrine response to surgery with higher circulating cortisol and catecholamines

 

Accurate quantification of alcohol intake is useful preoperatively and may provide insight into a given patient’s associated risk. Consumption below the levels traditionally associated with alcohol dependence have implications perioperatively. See table 1 for pathological effects. Consuming greater than 3 units per day is termed ‘hazardous drinking’ and is associated with increased surgical risk.

General recommendations

• Alcohol consumption should be documented as soon as possible prior to surgery. Chronic, low-level intake is extremely common in the elderly.
• Patients identified as ‘hazardous’drinkers (>3units daily) should be counselled regarding the increased perioperative risk that this confers. Abstinence prior to surgery should be advised.
• Where excessive alcohol consumption is identified, consideration should be given to more formal abstinence regimes involving specialist healthcare professionals
• Where excessive drinking is identified, investigations seeking end-organ damage should be performed. Treatment plans should also be put in place for the management of alcohol withdrawal syndromes perioperatively

Smoking

A long recognized and independent surgical risk factor, smoking remains the leading preventable cause of morbidity and mortality in the developed world.

The pathological effects of smoking include:

System	Effects of smoking	Associated complications
Respiratory	Dysfunction of the mucociliary escalator, poor clearance of pathogens. Macrophage dysfunction. Alveolar destruction and impaired gas exchange. Bronchial hyper-reactivity.	Unplanned intubation. Post-op mechanical ventilation. Pneumonia.
Cardiovascular	Endothelial injury and thrombogenesis. Increased blood viscsity. Formation of carboxyhaemoglobin. Sympathetic response of nicotine.	Myocardial infarction. Post-operative cardiac arrest. Stroke.
Wound healing	Free readical release and direct cellular injury. Local tissue vasoconstriction. Impaired collagen synthesis.	Wound infection. Sepsis and septic shock.

 

The preoperative period represents an ideal ‘teachable moment’ for clinicians to provide smoking cessation advice.

The use of scoring systems can be used perioperatively to guide the use of nicotine replacement therapy (e.g Fagerstrom score) ? table?

General recommendations

• Smoking cessation prior to surgery should be encouraged no matter how short the window is prior to surgery
• Surgery is increasingly recognised as a teachable moment for smoking cessation and the opportunity to try to influence long-term behaviour should be taken
• Preoperative assessment clinics should be able to provide written advice on how patients can access nicotine replacement therapy and smoking cessation services