A 15-year-old patient scheduled for anterior cruciate ligament repair under general anesthesia acknowledges the use of electronic cigarettes (e-cigarettes), or vaping, during preoperative evaluation. According to a recent review article, which of the following is the MOST appropriate perioperative care strategy for this patient who uses e-cigarettes?
(A) Prolonged postoperative monitoring X
(B) Use of total intravenous anesthesia intraoperatively X
(C) Preoperative e-cigarette cessation ✔
Read the discussion below.
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Over the past several decades there has been a decrease in cigarette smoking by adolescents because of a coordinated effort among physicians, communities, and policy makers. However, since the introduction of e-cigarettes into the United States over a decade ago, vaping by teenagers has increased dramatically. From 2011 to 2015 there was a 900% increase in e-cigarette use among US middle and high school students. By 2019, an estimated 27.5% of high school students reported vaping within the past 30 days. E-cigarettes are now the tobacco-based products most commonly used by youth in the United States. Because of this increased use by the pediatric population, the American Society of Anesthesiologists, the Society for Pediatric Anesthesia, and the American Academy of Pediatrics recently published a review on the perioperative implications of vaping.
Although e-cigarettes were once marketed to be a safer alternative to cigarette smoking, vaping can result in substantial health consequences. Individuals who use e-cigarettes compared with nonsmokers have increased odds of developing chronic bronchitis, emphysema, or chronic obstructive pulmonary disease. Additionally, there is a 5 to 7 times increased risk of a COVID-19 diagnosis in e-cigarette users compared with those who do not vape. In 2019, e-cigarette or vaping product use–associated lung injury (EVALI) was identified. Tetrahydrocannabinol (THC)-containing products have been most commonly associated with EVALI. These products also contain vitamin E acetate, which has been found in the lungs on bronchoscopy and could imply an association. Patients with EVALI present with respiratory symptoms, such as hypoxia, chest pain, and shortness of breath that can progress to acute respiratory distress syndrome. Additionally, gastrointestinal symptoms, such as nausea and vomiting, diarrhea, and abdominal pain, may present concurrently. These patients typically have bilateral diffuse lung opacities and require bronchoscopy to eliminate infectious etiologies for their symptoms. The only available treatment has been supportive care such as supplemental oxygen, ventilatory support, vaping cessation, and glucocorticoids. Studies have shown patients develop persistent increased airway reactivity and impaired diffusion capacity that persists for several weeks following their initial lung injury. There are no clear patient risk factors, but underlying asthma may predispose a patient to developing EVALI.
Traditional cigarette smoking has been known to increase perioperative complications, including bronchial reactivity, pulmonary complications, hospital length of stay, rate of hospital readmission, and delayed wound healing. Vaping appears to be equally detrimental to wound healing and results in ventilation-perfusion mismatching that can worsen immediately after vaping in patients who use e-cigarettes daily for at least 1 year. Because of the similarities between cigarette smoking and vaping, identifying perioperative complications and understanding the implications for perioperative care in a patient who uses e-cigarettes are important. The following recommendations have been made based on the current understanding of vaping and e-cigarette use in pediatric patients:
- Preoperative and long-term postoperative cessation of e-cigarettes should be encouraged. Patients should be screened for e-cigarette use preoperatively, and preoperative clinicians should consider referral to tobacco cessation strategy therapies.
- Preoperative evaluation should attempt to identify patients who are using THC-containing e-cigarettes, which puts them at risk of developing EVALI.
- If a preoperative patient is suspected of having EVALI, workup should include a smoking history and physical including vital signs and pulse oximetry. If respiratory symptoms are present, a chest x-ray or computed tomography can be helpful as well as consultation with a pulmonologist. Currently, there are no recommendations on when it is safest to proceed with an anesthetic following EVALI.
- No current guidelines are available to guide the intraoperative management of patients who vape.
- There is no evidence that supports extended postoperative monitoring in patients with a history of vaping.
Because of increased use of e-cigarettes by the pediatric population, anesthesiologists should understand the perioperative complications of vaping and should encourage vaping cessation preoperatively. Given the relatively recent introduction of e-cigarettes, much remains to be determined before formal recommendations can be made regarding intraoperative management in these patients as well as long-term impact on adolescent health.
- Rusy DA, Honkanen A, Landrigan-Ossar MF, et al. Vaping and e-cigarette use in children and adolescents: implications on perioperative care from the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine. Anesth Analg. 2021;133(3):562-568. doi:10.1213/ANE.0000000000005519
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