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Can Vaping Derail ERAS Protocols in Cardiac Surgery?

Traditional cigarette smoking is a risk factor for poor postoperative outcomes with preoperative abstinence reducing this risk. Smoking cessation is one component of the Enhanced Recovery After Cardiac Surgery (ERAS) multi-modality approach to preoperative optimization. The current guidelines recommend cessation (quitting smoking) four weeks prior to a scheduled operation.

Smoking as a Major Risk Factor

ERAS protocols and outcomes are not immune to the effects of cigarette smoking on cardiac, respiratory, and wound-related complications. Implementation research of ERAS protocols in other areas of surgery (hepatobiliary and pancreatic) have shown smoking as a major risk factor for failure. (Lee et al.)

Historically, it was enough to categorize smoking history by current, former, or never smoker and by pack years. Now, with the surge in E-cigarette use, known as vaping, over the past decade, categorizing smoking by the type of nicotine vector is crucial to researching and understanding the specific effects of E-cigarettes on health outcomes.

The danger of E-cigarettes lies in the shared components with traditional cigarettes: nicotine and aerosolized chemicals.

Limited evidence suggests E-cigarettes may produce similar physiologic changes as traditional cigarettes, leading to significant deleterious health effects.

With 1 in 20 Americans now using E-cigarettes, we are seeing these users as patients in our clinics and in the operating room. While vaping has not been specifically studied in cardiac surgery, data is beginning to emerge on the cardiac effects of E-cigarettes.

A recent study from the University of Kansas found e-cigarette users were 56 percent more likely to have a heart attack, 30 percent more likely to suffer a stroke, and 10 percent more likely to have coronary artery disease compared to non-smokers.

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How does this fit into ERAS protocols?

Efforts should target cessation of all smoking, including vaping, prior to surgery. As the vaping epidemic has only developed over the past decade, most electronic medical records have lagged behind in accurately capture of vaping status.

It is not enough just to ask a patient if they smoker; vaping must be specifically addressed. As research develops on the long-term effects of vaping, providers should inquire about vaping status preoperatively and proceed with a recommendation of cessation of all nicotine products, including vaping, prior to surgery.


About Mary Kate Bryant, MD

Dr. Mary Kate Bryant is a research resident in the Trauma Research Division at WakeMed Health & Hospitals and a fourth year General Surgery Resident at the University of North Carolina (UNC) at Chapel Hill.

Dr. Bryant received her medical degree from the University of Alabama at Birmingham and is currently pursuing a Master’s in Science of Clinical Research at the UNC Gillings School of Global Public Health. She is the first surgery resident to serve in this partnership between UNC and WakeMed Hospitals.

Dr. Bryant’s research interests include long-term clinical outcomes after trauma and the surgical care of vulnerable populations.

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