Zusammenfassung
Seit vielen Jahren wird angenommen, dass Zigarettenkonsum innerhalb von 6 Stunden vor Anästhesie die Inzidenz kardiopulmonaler Komplikationen und hier v. a. das Risiko der Aspiration erhöht. Patienten werden daher angewiesen, das Rauchen spätestens am Vorabend der Operation zu beenden. Ein Verstoß gegen dieses Verbot führt meist solange zur Verschiebung der Anästhesie, bis die Nüchternheitsgrenze (6 h) wieder eingehalten ist. Ziel dieser Übersicht ist es, den wissenschaftlichen Hintergrund des kurzfristigen präoperativen ‚Rauchverbots‘ (der Nutzen einer langfristigen Nikotinkarenz ist unbestritten) kritisch zu hinterfragen. Der Einfluss einer kurzfristigen (6 h) präoperativen Nikotinkarenz auf die perioperative pulmonale Morbidität ist bislang nicht untersucht. Ein mittelfristiger Rauchstop (<1-2 Monate) scheint die Inzidenz perioperativer pulmonaler Komplikationen nicht zu senken, sondern sogar zu steigern. In Hinblick auf das Aspirationsrisiko erhöht ‚akutes’ Rauchen weder Volumen noch Azidität des Magensafts. Eine Abnahme des Tonus des unteren Ösophagussphinkters ist bereits wenige Minuten nach Ende des Rauchens nicht mehr nachweisbar. Auch die Entleerung von flüssigem Magensaft bleibt unbeeinflusst. Feste Nahrung wird zwar nach Zigarettenkonsum langsamer aus dem Magen befördert als bei Nicht-Rauchern. Für Patienten, die meist am Vorabend der Operation die letzte feste Mahlzeit zu sich nehmen, dürfte dieser Effekt jedoch keine klinische Relevanz besitzen. Das in der Anästhesie bis heute dogmatisch vertretene präoperative Rauchverbot ist somit nicht mit einem sonst erhöhten Risiko für Aspirationen oder pulmonalen Komplikationen begründbar. Allerdings scheint akutes Rauchen (u. a. durch Erhöhung von COHb) die Inzidenz von Myokardischämien zu erhöhen. In Hinblick auf kardiale Komplikationen erscheint es daher sinnvoll, speziell Patienten mit kardialem Risiko nicht nur mittel- und langfristig, sondern auch kurzfristig präoperativ vom Zigarettenkonsum abzuraten.
Abstract
For decades it has been assumed, that smoking within 6 hours of anesthesia and surgery raises the incidence of perioperative cardiopulmonary complications (PPC) including aspiration. Therefore, every patient is adviced to stop smoking at the day before surgery, and not to smoke at all at the day of surgery. If the patient does not follow this advice, this will result in a postponement of anesthesia and surgery. The present article aims at re-investigating the scientific basis of this dogma in anesthesia, which virtually forbids smoking at short-term prior to surgery. The influence of short-term (6 h) abstinence from smoking on the perioperative pulmonary morbidity has not been systematically investigated. Interestingly, giving up smoking less than two months prior to surgery does not significantly decrease, but rather may increase the incidence of PPC. With respect to the risk of aspiration, smoking does not increase either the volume or the acidity of gastric juices. A short-lived reduction in the tone of the lower esophageal sphincter is reversible within minutes after termination of smoking. While the emptying of liquid gastric juices is not influenced by smoking, there is a certain delay in the propulgation of solid food. This effect, however, is probably of no clinical relevance in patients, who had their last solid meal the evening before surgery. Hence, we conclude that the anesthesia dogma, which rules out smoking shortly prior to anesthesia, cannot be based on an otherwise increased incidence of pulmonary aspiration or other pulmonary morbidity. However, acute smoking (probably by an increase in COHb) may increase the incidence of myocardial ischemia during exercise and anesthesia. With reference to this possible cardiac complication it still seems reasonable to discourage smoking at least 12 to 48 hours prior to surgery in patients with elevated cardiac risk.
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* Dogma (griechisch): „Formulierung von feststehenden Lehrsätzen, deren Voraussetzungen außerhalb der Möglichkeiten wissenschaftlicher Nachprüfung liegen“. Auch: Grundüberzeugung, die gegen Zweifel nicht durch Beweis, sondern durch autoritative Erklärung gesichert ist (Meyers Enzyklopädie).
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Zwissler, B., Reither, A. Das präoperative „Rauchverbot“. Anaesthesist 54, 550–559 (2005). https://doi.org/10.1007/s00101-005-0851-0
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DOI: https://doi.org/10.1007/s00101-005-0851-0