What preoperative recommendations should be made for a 68-year-old woman with COPD, myocardial disease, and a smoking history to reduce postoperative complications before a scheduled hysterectomy?

Preoperative Smoking Cessation with Nicotine Replacement Therapy is Essential for COPD Patients Before Surgery

For this 68-year-old woman with COPD and cardiac disease who smokes, smoking cessation with nicotine replacement therapy should be initiated immediately before discharge to optimize surgical outcomes for her upcoming hysterectomy. 1

Rationale for Smoking Cessation Before Surgery

Smoking is a significant risk factor that increases postoperative complications, particularly in patients with existing COPD and cardiac disease. The evidence strongly supports smoking cessation before elective surgery:

• Smoking increases the risk of intra- and postoperative complications, especially respiratory and wound-healing complications 1
• Patients with COPD who smoke have higher rates of postoperative pulmonary complications 1
• Smoking cessation of 4-8 weeks before surgery provides the most significant reduction in complications 1

Specific Benefits for This Patient

This patient has multiple high-risk factors that make smoking cessation particularly important:

• COPD: Smoking exacerbates COPD symptoms and increases risk of postoperative pulmonary complications 1
• Cardiac disease: Smoking accelerates coronary artery disease and increases risk of perioperative cardiac events 2, 3
• Upcoming major surgery (hysterectomy): Smoking increases risk of surgical site infections, delayed wound healing, and pulmonary complications 1

Implementation Plan

1. Immediate intervention before discharge:

   • Provide smoking cessation counseling while the patient is still hospitalized 1, 4
   • Offer nicotine replacement therapy to manage withdrawal symptoms 1, 4
   • Set a quit date immediately, as even short-term cessation can provide benefits 1

2. Post-discharge support:

   • Arrange for continued counseling after discharge 4
   • Maintain nicotine replacement therapy for at least 1 month after discharge 4
   • Schedule follow-up to monitor compliance and address challenges 1

Evidence for Hospital-Based Intervention

The Cochrane review on interventions for smoking cessation in hospitalized patients found that:

• Intensive counseling interventions that begin during hospitalization and continue with supportive contacts for at least one month after discharge significantly increase smoking cessation rates 4
• Adding nicotine replacement therapy to intensive counseling further increases cessation rates 4

Why Other Options Are Not Preferred

• Preoperative stress test: While cardiac evaluation may be warranted given her cardiac history, smoking cessation has a more immediate and broader impact on reducing perioperative complications 1
• Stopping beta-blocker: Beta-blockers should be continued perioperatively in patients with cardiac disease, not discontinued 1
• Preoperative corticosteroid burst: Not indicated as a routine preoperative measure for COPD patients who are not having an acute exacerbation 1

Special Considerations for COPD and Cardiac Disease

Patients with both COPD and cardiac disease represent a particularly high-risk group:

• COPD patients have higher mortality and complication rates after surgery 5
• COPD and coronary artery disease share pathophysiological mechanisms beyond smoking 2
• COPD patients with cardiac disease often receive suboptimal cardiac care 6, 5

Monitoring and Follow-up

• Schedule regular follow-up calls or visits to reinforce smoking cessation
• Monitor for withdrawal symptoms and adjust nicotine replacement therapy as needed
• Assess respiratory status before surgery to establish baseline
• Consider pulmonary rehabilitation if time permits before surgery

By implementing smoking cessation with nicotine replacement therapy now, you can significantly improve this patient's surgical outcomes and potentially provide long-term health benefits for both her COPD and cardiac conditions.