18. Smoking And Wound Healing


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18. Smoking And Wound Healing

  1. 1. Smoking and Wound Healing
  2. 2. Smoking & Wound Healing Risk factors of poor wound healing  Smoking  Diabetes  Malnutrition  Presence of foreign bodies  Metabolic disease  Drugs  Underlying disease of soft tissue or bone
  3. 3. Smoking and Wound Healing
  4. 4. Smoking & Wound Healing Causes of delayed wound healing  Wound infection  Tissue hypoxia  Repeated trauma  Presence of debris  Necrotic tissue
  5. 5. Smoking & Wound Healing Post-operation outcome(1)  2Sorensen et al. 9x ↑ and 4x ↑ in wound necrosis and wound infection after reconstructive breast surgery and mastectomy respectively in smokers  3Cobb et al. Smokers have up to 8x higher risk of re-operation because of incomplete bone fusion
  6. 6. Smoking & Wound Healing Post-operation outcome(2)  4Lind et al. Higher incidence of delayed healing and wound infection, including 2.5 fold increased risk of amputation in smokers compared to non-smokers  Sorensen et al. 5 Recurrence of groin hernia within 2 year after herniotomy occurs 2x more often in smokers 6 Disruption of anastomoses of the colon and rectum occurs 3x more often in smokers
  7. 7. Smoking & Wound Healing Pathogenic Mechanisms(1) 1. HYPOXIA  Nicotine  Induces epinephrine release →increases BP and HR →peripheral vasoconstriction →reduced peripheral tissue blood flow by up to 40%
  8. 8. Smoking & Wound Healing Pathogenic Mechanisms(2)  Carbon Monoxide  200x higher Hb binding affinity than O2  Carboxyhaemoglobin reduces O2 concentration  Changes O2 dissociation curve→reduces O2 diffusion ability from Hb molecule to peripheral tissue
  9. 9. Smoking & Wound Healing Pathogenic Mechanisms(3)  Delays production of collagen →d/t reduced O2 tension (<40mmHg)  7 Degrades connective tissue and collagen (mechanism unclear) →d/t higher concentration of neutrophils  Infection  Smoking impairs bactericidal mechanisms  Defence reduced up to 50% especially Staphylococcus aureus and Escherichia coli
  10. 10. Smoking & Wound Healing Are wound complications preventable by smoking cessation? Sorensen et al.  8Oxidative killing of neutrophils is restored to the level of non-smokers by 3 weeks of abstinence.But, Type I collagen synthesis did NOT restore by 3 weeks of abstinence  9 Smokers have 6 fold higher incidence of wound rupture and 6 fold higher incidence of wound infection.  Wound infection rate decreased by 30 percent after 4 weeks of abstinence  but wound rupture rate were not affected by 4,8,12 weeks of abstinence
  11. 11. Smoking & Wound Healing Are wound complications preventable by smoking cessation?  Short-term cessation of smoking (2-3 weeks) 10 does not reduce the risk of complicated tissue and wound healing or other complications in colorectal surgery.
  12. 12. Smoking & Wound Healing Summary  Smoking is an important risk factor for complication of wound healing  Smoking causes tissue hypoxia which impairs collagen synthesis and impedes bactericidal activity.  Oxidative killing of neutrophils can be restored by 3 weeks of abstinence and reduction of wound infection rate by 30% after 4 weeks of abstinence  At present, no sufficient evidence to suggest whether abstinence has an effect on collagen synthesis and wound dehiscence.
  13. 13. Smoking & Wound Healing Reference  Hess, CT. Nurse's Clinical Guide: Wound Care. Springhouse, Pa: Springhouse Corp; 1995:1-14, 74-81, 92-260.  Sorensen LT, Horby J, Friis E, Piilsgaard B, Jorgensen T. Risk factors for impaired wound healing and infection in breast cancer surgery. EUR J Surg Oncol 2002; 28: 815-20.  Cobb TK, Gabrielsen TA, Campbell DC, Wallrichs SL, Ilstrup DM. Cigarette smoking and nonunion after after ankle arthrodesis. Foot.Ankle Int 1994; 15:64-7.  Lind J, Kramhoft M, Bodtker S. The influence of smoking on complications after primary amputations of the lower extremity. Clin Orthop 1991; 267:211-7  Sorensen LT, Friis E, Jorgensen T, Vennits B, Andersen BR, Rasmussen GI, Kjaergaard J. Smoking is a risk factor for recurrence of groin hernia. World J Surg 2002; 26, 397-400
  14. 14. Smoking & Wound Healing Reference (2) 6. Sorensen LT, Jorgensen T, Kirkeby LT, Skovdal J, Vennits B, Wille JP.Smoking and alcohol abuse are major risk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999; 86: 927-31  MsCusker K. Mechanisms of respiratory tissue injury from cigarette smoking. Am J Med 1992; 93:18S-21S  Sorensen LT, Nielsen HB, Kharazmi A, Karlsmark T, and Gottrup F. Abstinence from smoking enhances neutrophil bactericidal activity and reduces wound infection. Surgery. 2004 Nov;136(5):1047-53  Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection. A randomized control trial. Ann Surg. 2003 Jul;238(1):1-5  Sorensen LT, Jorgensen T. No effect of short term preoperative smoking intervention on postoperative tissue and wound complications in Colorectal surgery. A randomized clinical trial. Colorectal Disease. 2003 Jul;5(4):347-52  Sorensen LT. Smoking and wound healing. EWMA Journal. 2003; Vol 3 no. 1
  15. 15. Smoking & Wound Healing Phases of Wound Healing  Inflammatory phase (immediate - 2-5 days)  Haemostasis  Inflammation  Proliferative phase (2 days - 3 weeks)  Granulation  Contraction  Epithelialization  Remodeling phase (3 weeks - 2 years)
  16. 16. Smoking & Wound Healing Wound Healing Pathway Souce: Adapted from reference hess