Passive Smoke Exposure (PSE) is Correlated with Perioperative Adverse Effects in Children that Undergo General Anesthesia: A Prospective,

Double-blind, Clinical Study.

Tulay Hosten SeyidovTulay Hosten Seyidov11, Levent Elemen, Levent Elemen22, Mine Solak, Mine Solak11, Melih , Melih TugayTugay22, Kamil Toker, Kamil Toker11

Kocaeli University Medical SchoolKocaeli University Medical School1-Anesthesiology and Reanimation Department1-Anesthesiology and Reanimation Department

2-Pediatric Surgery Department2-Pediatric Surgery Department

IntroductionIntroduction

Passive smoke exposure relates to smoke of lit tobacco in locations where tobacco is smoked as well as the inhaling of air contaminated with mixture of exhaled tobacco smoke.

IntroductionIntroduction

Tobacco smoke seriously damages human health due to its high contents of ammonium, benzene, nicotine, CO and various carcinogens.

IntroductionIntroduction

In children exposed to tobacco smoke, asthma and airway reactivity are more frequently encountered and lower airway infections increase in infants.

Middle ear infections are also known to increase due to deterioration of cellular and mucociliary functions in upper airways.

Chilmonczyk B, N Engl J Med, 1993.

Wrihgt AL, J Pediatr, 1991. Etzel RA, Pediatrics, 1992.

IntroductionIntroduction

It is also reported that in case children exposed to tobacco smoke undergo general anesthesia, airway complications increase.

Skolnick ET, Anesthesiology, 1998.

ObjectivObjectivee

The objective of our study is to investigate Passive Smoke Exposure (PSE) prevelance and its relation with Perioperative Respiratory Adverse Events (PRAE) in children operated under general anesthesia.

Materials and MethodsMaterials and Methods

Patients between the ages of 3 months to 12 years operated in Kocaeli University Medical School operating theaters under general anesthesia between 01 June and 30 September 2008 were included in this prospective, double-blind study after the approval of the local ethics committee was obtained.

Materials and Materials and MethodsMethods

PRAE was defined as: • Coughing (3 or more episodes wit each Coughing (3 or more episodes wit each

episode lasting at least 5 seconds)episode lasting at least 5 seconds)• Laryngospasm (requiring active glottic Laryngospasm (requiring active glottic

widening)widening)• Increase in airway secretions Increase in airway secretions • Breath holding (lasting for more than 15 Breath holding (lasting for more than 15

seconds)seconds)• Bradycardia (Drop of HR by 50% from its basal Bradycardia (Drop of HR by 50% from its basal

value) value) • Desaturation (SpO2 < 95%) .Desaturation (SpO2 < 95%) .

Materials and MethodsMaterials and Methods

• In all the patients, anesthesia induction was performed by at least one specialist and two anesthesia assistants with at least two years of experience.

• PRAE was evaluated during anesthesia (induction-emergence) and following anesthesia (recovery) by anesthesia specialist who performed the anesthesia induction of the child and who was unaware of PSI.

Materials and MethodsMaterials and Methods

• PSEPSE was defined as smoking was defined as smoking a minimum of a minimum of 1010 cigarettes at home cigarettes at home in the presence ofin the presence of the child or the child or in another roomin another room..

• It was questioned by It was questioned by anamnesesanamneses taken taken from the parents and/or attendants of the from the parents and/or attendants of the child by the recovery nurse who was child by the recovery nurse who was unawareunaware of PRAE following anesthesia, in of PRAE following anesthesia, in the recovery phase.the recovery phase.

Statistical Analysis

• NCSS 2007 & PASS 2008 software was used.

• In addition to definitive statistical methods (Mean, Standard Deviation), Student’s t test and Mann Whitney U test was used in the evaluation quantitative data and Chi-square test and Fisher’s Exact Chi-square test were used in the comparison of qualitative data.

• The results were considered to be in the 95% confidence interval and significance as p<0.05.

ResultsResults

• 239 patients were evaluated throughout the study.

• 17 patients with acute or chronic airway or lung diseases, asthma and who received medical treatment due to coughing in the last six weeks were excluded from the study.

222

CONTROL101

45.5%

PSE121

54.5%

FATHER70

57.8%

MOTHER12

9.9%

MOTHER+FATHER

3932.2%

Groups

PSE

n: 121

Control

n: 101

Mean±SD

Mean±SD

p

Age (years) 3.91±3.20 3.95±3.37 0.94 Weight (kg) 16.55±8.79 15.59±7.84 0.39

Anesthesia time (min) 71.6±47.77 65.00±30.67 0.21

Operation time (min) 64.84±46.81 58.37±29.54 0.21

n (%) n (%)

Females 37 (30.6) 38 (37.6) Gender

Males 84 (69.4) 63 (62.4) 0.26

I 104 (86.0) 92 (91.1) ASA

II 17 (14.0) 9 (8.9) 0.23

Rectal midazolam 59 (48.8) 54 (53.5)

Iv. midazolam 47 (38.8) 34 (33.7) Premedication

None 15 (12.4) 13 (12.9)

0.72

Use of muscle relaxants (yes/no) 59 (48.8) 57 (47.1) 0.85

Difficult ventilation 1 (0.8) 1 (1.0) 1.00

Inhalation 87 (71.9) 83 (82.2) Induction

Intravenous 34 (28.1) 18 (17.8)s 0.07

ETT 60 (49.5) 52 (51.4) Airways

IMA proseal 61 (50.5) 49 (48.6) 0.64

Parenteral 42 (34.7) 24 (23.8)

Rectal paracetamol 44 (36.4) 43 (42.6)

Caudad and peripheral nerve block

17 (14.0) 18 (17.8)

Postop. Analgesia

None 18 (14.9) 16 (15.8)

0.34

Otolaryngology 14 (11.6) 14 (13.9)

Urology 40 (33.1) 42 (41.6)

Orthopedics 25 (20.7) 18 (17.8)

Surgical procedure

Others 42 (34.7) 27 (26.7)

0.44

PRAE

23

( % 10.4 )

PSE 17

( % 14.1 )

CONTROL6

( % 6 )

Groups

PSE

(n=121)

Control

(n=101)

n (%) n (%)

p

During Anesthesia 2 (1.7) 2 (2.0) 0.85 Coughing In Recovery 2 (1.7) 0 0.50

During Anesthesia 1 (0.8) 1 (1.0) 1.00 Laryngospas

m In Recovery 0 0

During Anesthesia 2 (1.7) 1 (1.0) 1.00 Increase in

upper airway

secretions In Recovery

5 (4.1) 1 (1.0) 0.22

During Anesthesia 1 (0.8) 0 1.00 Breath

holding In Recovery 1 (0.8) 0 1.00

During Anesthesia 1 (0.8) 0 1.00 Bradycardia

In Recovery 0 0

During Anesthesia 2 (1.7) 1 (1.0) 1,000 Desaturation

In Recovery 0 0

During Anesthesia 9 (7.5) 5 (5.0) 0.44

In Recovery 8 (6.6) 1(1.0) 0.04*

Total 0.04*

ResultsResults

The recovery times

PSE: 5.89±7.37 min Control: 4.86±4.49 min P=0.22

DiscussionDiscussion

A study shows that PSE and airway complications are very strongly correlated in children who undergo general anesthesia.

Another study asserts that in the absence of upper airway tract infection, PSE does not affect airway complications.

Skolnick ET, Anesthesiology, 1998.

Mamie C, Pediatric Anesthesia, 2004

DiscussioDiscussionn

PSE increases postextubation laryngospasm, PSE increases postextubation laryngospasm, oxygen desaturation, coughing and breatoxygen desaturation, coughing and breat holding incidence in the recovery roomholding incidence in the recovery room..

Chilmonczyk B, N Engl J Med, 1993.Chilmonczyk B, N Engl J Med, 1993. Wrihgt AL, J Pediatr, 1991.Wrihgt AL, J Pediatr, 1991. Etzel RA, Pediatrics, 1992.Etzel RA, Pediatrics, 1992.

DiscussionDiscussion

Although we did not find significant differences in the distribution of complications, the high number upper airway secretions, particularly in the recovery phase, is remarkable.

For the distribution of complications become statistically significant, 160 more patients are still required and therefore, our study is continuing.

DiscussionDiscussion

Smoke exposure causes goblet cell metaplasia and excess mucus production in the small airways and proximal trachea.

In animals smoke inhalation studies demonstrated increases in the number of goblet cells in the proximal trachea.

Churg A, Am J Physiol Lung Cell Mol Physiol, Churg A, Am J Physiol Lung Cell Mol Physiol, 2008 2008

Jones R, Br.Med j, 1972Jones R, Br.Med j, 1972

DiscussionDiscussion

Increased upper airway secretions in the recovery phase may be attributed to the increase in the number of goblet cells and excess mucus production.

DiscussioDiscussionn

Despite this, the similarity of recovery times in both groups can be attributed to the fact that our nurses have vast experience and to the exclusion from the study of those patients that have risk factors that would lead to an increase in respiratory complications along with PSE.

DiscussioDiscussionn

• Defining PSE by anamnesis taken from the family rather that via cotinin levels might be considered a weak aspect of our study.

• While there are studies asserting that family anamnesis is unrealistic in PSE, there are other studies showing that urine cotinin levels are in accordance with family anamnesis as well.

• A study suggests that questioning PSE with family anamnesis would be a practical but valuable method.

Boyacı H, Pediatr Int, 2006.

Skolnick ET, Anesthesiology, 1998. Jones DT, Otolaryngol Head Neck Surg,

2006.

DiscussionDiscussion

Considering that collecting blood and urine samples in the preoperative period would be costly and tiresome, we preferred questioning PSE via family anamnesis in our study.

ConclusionConclusion

PSE has increased PRAE's of children that received general anesthesia.

When that PSE prevelance was 54.5% is considered, it can be argued that questioning PSE in the preoperative period is important in the prevention of respiratory complications due to general anesthesia.