From Clinic to Recovery · First Edition
Chapter 27 — Smoking, Alcohol, and Medicine Reconciliation
Dr. Tamer Rushdy Elalfy · 6 min read
Three ordinary tasks prevent a disproportionate share of surgical complications: helping a patient stop smoking, identifying and managing risky alcohol use, and making sure the medicine list used at every stage of care is accurate. None of them need advanced technology. All three are easy to skip in a busy clinic, and all three are proven to change outcomes. This chapter brings together the smoking and alcohol advice referenced throughout the book and adds the discipline of medicine reconciliation.
Learning objectives After reading this chapter you should be able to:
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27.1 Smoking cessation
Stopping smoking before surgery reduces wound and lung complications, and the effect is seen even when cessation starts shortly before the operation; a systematic review found that smoking cessation beginning as little as 4 weeks before surgery reduced complications, and found no evidence that quitting shortly before surgery increases risk, a concern that had previously discouraged some clinicians from raising it late [1]. The message for every patient, at every visit, is simple: the earlier you stop, the better, but it is still worth stopping even close to the operation. Ask about shisha and vaping as well as cigarettes, since many patients do not count these as smoking.
Script: brief smoking intervention “Do you currently smoke cigarettes, shisha, or vape? Would you be interested in stopping before your operation?” “Stopping now, even a few weeks before surgery, lowers your risk of wound and chest problems, and it is never too late to start.” “We can offer you support and nicotine replacement to make it easier. Would you like a referral?” |
27.2 Alcohol
Ask every patient about alcohol use before surgery, using a simple, non-judgmental question about how much and how often they drink. Heavy regular drinkers have higher rates of wound infection, bleeding, heart problems, and poor wound healing, and benefit from stopping or reducing before elective surgery, ideally around 4 weeks beforehand (Chapter 2) [2]. The more urgent safety issue is withdrawal: a patient who drinks heavily every day and stops suddenly around surgery is at risk of alcohol withdrawal, which can progress to seizures and delirium tremens. Ask specifically about daily drinking before elective surgery, and refer heavy daily drinkers for medically supervised withdrawal rather than asking them to stop abruptly on their own.
Caution: alcohol withdrawal is a medical emergency Signs of withdrawal (tremor, sweating, agitation, hallucinations, or seizures) typically begin 6 to 24 hours after the last drink and can escalate quickly in a hospitalized patient who is unable to drink. Ask about daily alcohol use on admission for every surgical patient, and have a withdrawal management protocol ready for those at risk. |
27.3 Medicine reconciliation
Medicine reconciliation means comparing the medicines a patient is actually taking against what is written in the chart, at every point where care changes: clinic to admission, admission to operating room, operating room to ward, and ward to discharge. Errors are common at each of these points, and many are preventable [3]. A complete medicine history includes prescription medicines, over-the-counter medicines, herbal and traditional remedies, vitamins, and injections such as weight-loss or diabetes medicines that patients may not think to mention.
Table 27.1. Medicine reconciliation at each transition of care.
| Transition | What to check |
|---|---|
| Clinic to admission | Full medicine list, including herbal remedies, OTC medicines, and injections; allergies |
| Admission to surgery | Which medicines were actually taken that morning, against the written plan |
| Surgery to ward | Medicines given during surgery; resumption plan for home medicines |
| Ward to discharge | New medicines explained; old medicines resumed or deliberately stopped; written, reconciled list given to the patient |
Caution: writing clear medicine instructions Discharge instructions about medicines must say explicitly what to do, not leave it to be inferred. Write “Do NOT take metformin, gliclazide, or your water tablet on the morning of surgery unless your team tells you otherwise,” not a bare list of medicine names under a heading that could be read either way. Ambiguous wording is a preventable cause of patient harm. |
STEP 2 Putting it into practice
- Every visit. Ask about smoking, shisha, vaping, and alcohol at every preoperative visit, not only once.
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Every medicine list. Ask specifically about herbal remedies, supplements, and injections.
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Every transition. Reconcile the medicine list at admission, after surgery, and at discharge.
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Every instruction. Write what to do, not just what the medicine is, and say explicitly when something should NOT be taken.
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Every support offer. Make cessation support and withdrawal management easy to access, not something the patient has to ask for.
STEP 3 Questions patients ask
“Is it too late to stop smoking before my operation next week?”
No. Stopping even shortly before surgery is still worthwhile and does not increase your risk [1]. The earlier you stop, the greater the benefit, but any amount helps.
“I drink every day. Should I just stop before my operation?”
Please tell us exactly how much you drink. Stopping suddenly can be dangerous, so we may arrange supervised support rather than asking you to stop alone.
“Do I need to tell you about herbal remedies and vitamins?”
Yes, please. Some herbal remedies affect bleeding or interact with anesthesia.
“Why does the list of my medicines keep changing while I’m in hospital?”
We check your medicines at every step of your care to keep you safe. We will give you one final, clear list when you go home.
STEP 4 Key points
Key points
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References
1. Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59(3):268-279.
2. Tønnesen H, Nielsen PR, Lauritzen JB, Møller AM. Smoking and alcohol intervention before surgery: evidence for best practice. Br J Anaesth. 2009;102(3):297-306.
3. National Institute for Health and Care Excellence. Medicines optimisation (QS120) and NG5: medicines reconciliation. London: NICE, updated.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.
PART IV
Returning to Normal Life
Chapters 28 and 29
Patients judge an operation not only by the result but by how quickly and fully they return to their own life: intimacy, driving, exercise, travel, and work. These two chapters bring that question together across the whole book.