Management of heavy smokers in the intensive care unit

Abstract

Quitting smoking abruptly can precipitate the nicotine withdrawal syndrome, characterized by psychological and physical components. Data from critically ill patients have shown that active smokers are more likely to suffer from psychomotor agitation, self-removal of tubes and catheters, need for physical restraint, and therefore usually require higher doses of sedatives, neuroleptics, and analgesic agents. Furthermore, smokers admitted to the intensive care unit (ICU) experience delirium or agitation, which increases the length of hospital stay and the cost of medical care. Nicotine replacement therapy (NRT) has been shown to be safe and effective in the outpatient setting in smokers who intended to quit. However, the management of nicotine withdrawal symptoms in critically ill patients is controversial. Several studies have identified that treating nicotine withdrawal symptoms with NRT can be beneficial while others suggest that it can potentially increase mortality in critically ill patients. In the absence of high-quality data, NRT cannot currently be recommended for routine use to prevent delirium or to reduce hospital or ICU mortality in critically ill smokers. From the currently available data, it seems that the use of NRT in critically ill patients should be limited to selected patients where the potential benefit clearly outweighs the risk. To establish definitive conclusions regarding the use of NRT in smokers admitted to the ICU, it is necessary to carry out well-designed prospective studies with a sample of adequate size to limit the confounding factors and biases present in the current retrospective observational studies.