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5/2/2019 1
Steroids and Anesthetic Considerations
Sass Elisha Ed. D, CRNA, FAAN
Kaiser Permanente School of Anesthesia
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REGULATION OF THE HPA AXISStimulation Inhibition
CRH
Decreased cortisol
Transition from sleep to
awake
Physiologic Stress
Hypoglycemia
Trauma/Sepsis
Alpha and Beta-agonists
Adrenocorticotropic hormone (ACTH)
Increased cortisol
General anesthesia
Etomidate
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HPA Axis SuppressionWho should receive steroids preoperatively?
Old-Prednisone 5 mg/d or equivalent) for a period of ____weeks within_____year
New-Prednisone 20 mg/d or equivalent ____ weeks or longer within _____ year
HPA axis dysfunction is dependent on the _____ and ______of steroid therapy.
Borresen, et al. Eur J Endocrinol. 2017.
“Adrenal insufficiency is seen in more then 1/3 of those on low dose prednisolone treatment for rheumatoid arthritis-
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Drug Potency NA Retain Duration
Cortisol
(Hydrocortisone)
1 1 8-12h
Prednisone 4 0.8 18-36h
Dexamethasone 25 0 36-54h
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Various Steroids and Equipotent Dosages
Hydrocortisone 100 mg
Prednisone 25 mg
Methylprednisolone 20mg
Dexamethasone 3.75 mg
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Cortisol Secretion Cortisol secretion=Highest in the morning (20ug/dl)
Lowest around midnight (5ug/dl)
Normal daily output of cortisol=_________
Old-Maximum daily output cortisol= _____
New-Maximum daily output cortisol=_____
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Absorption of Exogenous Steroids
Absorption occurs by; inhalation, mucosal and skin applications.
Do patients taking steroids via inhalation IA injections need preoperative steroids? Epidural steroids?
In the history of the world, have any of these patients developed acute adrenal insufficiency?
Signs and Symptoms Associated with Acute Adrenal Crises
Neurologic
Hemodynamic
Metabolic-Hypoglycemic
Hypovolemia
Hyponatremic
Hyperkalemic
Metabolic acidosis
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Electrolyte Abnormality Associated with Acute Adrenal Crises
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Treatment of Acute Adrenal Crises Hydrocortisone 100 mg IV
Hydrocortisone 200 mg IV infusion over
24 hours
Fluid replacement
Glucose replacement and monitoring
Hemodynamic monitoring
Vasopressor and inotropic support as needed
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Minor Surgical Stress(inguinal hernia)25 mg hydrocortisone or equivalent
Moderate Surgical Stress(cholecystectomy, hysterectomy, colon resection)50-75 mg/d of hydrocortisone or equivalent for 1-2 d,then resume preoperative dosage
Major Surgical Stress(AAA repair, cardiac bypass)100-150 mg/d of hydrocortisone or equivalent for 2-3 daysthen resume preoperative dosage
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Etomidate-Inhibition of Cortisol
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Concerns about Etomidate and Acute Adrenal Crises
Higher mortality after Etomidate administration in patients with septicemia despite dosage
Alternative drug choices for induction in critically ill patients?
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Got STEROIDS for PONV?
Decadron most efficacious if given prior to induction of anesthesia
Decadron most effective dose??????????1. Onset 1 h
2. Peak 8-10 h
3. Duration 72 h
Multimodal therapy is superior
Should I give 100 mg hydrocortisone for potential adrenal insufficiency decadron for PONV preoperatively?
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Steroids and Septic Shock Sepsis=iNOS→increased
nitrioxide=vasodilator
Cytokines decrease #’s/affinity of glucocorticoid receptors for cortisol
Surviving sepsis campaign (SSC), 2016
200 mg hydrocortisone if ↓BP after volume
resuscitation and max vasopressors
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Venkatesh, et al. NEJM. 2018.
“Among patients with septic shock, a continuous infusion of hydrocortisone did not result in lower 90-day mortality than placebo.”
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Dexamethasone injected perineurally is more effective than administration intravenously for peripheral nerve blocks: A meta-analysis of RCT
Zorilla-Vaca A, et al. Clin J Pain. 2018.
Perineural Dexamethasone 4-5 mg compared with IV was associated with;
1. Decreased pain scores
2. Reduced opioid consumption
3. Less PONV
Analgesia with IV versus perineural Dexamethasone were similar at >8 mg
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Steroids and Interscalene Nerve BlocksCummings, et al. Br J Anaesth. 2011.
Grp A-Ropivacaine or Bupivacaine 0.5%
Grp B-Medication above w Decadron 8 mg
With Decadron-increased time of analgesia from 11-15 h to 23 h postop
Dexamethasone: Adjuvant to Femoral Nerve Block
Sherif, et al. Acta Anaesthesiol Scand. 2016.
When Decadron 8 mg added to Bupivacaine 0.5% for femoral nerve block;
Duration-Decadron 25.7 h vs 18.8 h plain Bupivacaine
Less morphine consumption 1st 6 h postop
Improved pain control postop day 1
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Steroids to Reduce Postoperative PainDe Oliveira, et al. BJA. 2011.
“Decadron 0.1 mg/kg is effective in reducing postoperative pain and decreasing opioid consumption after ambulatory gynecologic surgery.”
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.The efficacy of dexamethasone on pain and recovery after total hip arthroplasty:
A systematic review and meta-analysis of randomized controlled trials.Fan, et al. Medicine, 2018.
“Dexamethasone reduces postoperative pain scores, postoperative opioids consumption within 48 hours, postoperative vomiting and length of stay.”
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Steroids and Diabetes Physiologic stress-cortisol=gluconeogenesis
Decadron 10 mg IV significantly increases blood sugar 180 minutes post injection in healthy volunteers
Effects greatest in insulin dependent diabetics
A prospective randomized study on the impact of low-dose dexamethasone on perioperative blood glucose concentrations in
diabetics and nondiabetics. Athul P, et al Saudi J Anesth. 2018
Dexamethasone 8 mg causes a greater hyperglycemic response in nondiabetics compared to diabetics at 8 h post-administration.
Diabetics have an exaggerated hyperglycemic response at 4 h post-administration of 4 mg.
The maximum rise in blood glucose was in the range of 40–43 mg/dl in all patients with either 4 or 8 mg.
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Steroids and Cancer Risk No current evidence that perioperative Decadron
administration effects the rate on cancer survival
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Steroids and postoperative infection?Assante, et al. AANAJ. 2015.
“Although the majority of the literature reviewed found no association between single-dose intraoperative dexamethasone and an increase in surgical site infections, the need for a large-scale randomized controlled trial is consistently mentioned.”
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Safety and Epidural Steroid InjectionsAPSF, Feb-2016
FDA published “serious neurologic events” after epidural glucocorticoid injections.
Vision loss, CVA, paralysis, death
Associated with particulate steroid
preparation
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Steroids and ERAS after TKAScott. et al. Arch Orthop Trauma Surg. 2013.
Decadron 4 mg IV at induction decreases PONV, decreases time to ambulation, decreases postoperative pain.
No increased wound infection or bleeding
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Many References
Assante J, Collins S, Hewer I. 2015. Infection Associated With Single-Dose Dexamethasone for Prevention of Postoperative Nausea and Vomiting: A Literature Review. AANA J.83(4):281-8.
Athul P, et al. 2018. A prospective randomized study on the impact of low-dose dexamethasone on perioperative blood glucose concentrations in diabetics and nondiabetics. Saudi J Anesth. 2018:12(2): 198–203.
Awad K, Ahmed H, Abushouk AI.2016. Dexamethasone combined with other antiemetics versus single antiemetics for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: An updated systematic review and meta-analysis.Int J Surg. ;28(4):152-163.
Boonen E., Reduced cortisol metabolism during critical illness., 2013. NEJM, 1477-1488.
Borrensen SW. 2017. Adrenal Insufficiency is seen in more than one third of patients during ongoing low dose prednisolone treatment for rheumatoid arthritis. Eur J Endocrinol.;177(4):287-295.
Byrne, K. 2016. Can anesthetic-analgesic technique during primary cancer surgery affect recurrence or metastasis? Can J Anesth.;62(2):184-192.
Chan MC., Mitchell, AL., Shorr, AF. 2012. Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis. Crit Care Med, 40(11), 2945-2952.
Cummings KC., 2011. Effect of dexamethasone on the duration of interscalene nerve blocks with ropivacaine or bupivacaine. Br J Anaesth. 107(3),446-453.
De Oliveira GS., 2011. Dose ranging study of the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after gynecologic surgery, BJA, 3, 362-371.
Elisha S, Gabot M, Giron S. 2011. Steroids. In Pharmacology for Nurse Anesthesiology, Ouelette R, Joyce J, eds. 303-311.
Fan ZR, Ma J, Ma XL, Wang Y, Wang Y. 2018. The efficacy of dexamethasone on pain and recovery after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 97(13).
Freudzon L. 2018. Perioperative Steroid Therapy: Where’s the Evidence? Current Opinion.;31(1):31-43.
Fujii Y, Itakura M. 2010. Reduction of postoperative nausea, vomiting, and analgesic requirement with dexamethasone for patients undergoing laparoscopic cholecystectomy. Surgical Endoscopy, 24, 692-696.
Jakobsson J., 2010.Preoperative single dose intravenous dexamethasone during ambulatory surgery. Curr Opin Anesthes. 23, 682-686.
Khan Shariq., 2013. Wound complications and dexamethasone, Anesth & Analg. 116(5), 965-967.
Legrand M., Plaud, B. 2013. Etomidate and general anesthesia: The butterfly effect? Anes & Analg, 117(6) 1267-1268.
Liu M., 2017. Perioperative steroid management. Anesthesiology, 127(1), 166-172. Low Y., White WD, Habib AS. 2015.Postoperative hyperglycemia after 4- vs 8-10-mg
dexamethasone for postoperative nausea and vomiting prophylaxis in patients with type II diabetes mellitus: a retrospective database analysis. J Clin Anesth. 27(7):589-94.
Ljungqvist, O. 2017. Enhanced Recovery After Surgery: A Review. JAMA Surgery.152(3), 292-298.
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Marik PE, Varon J. 2008. Requirement of postoperative stress doses of corticosteroids. Arch Surg. 143(12), 1222-1226.
Merk BA, Havrilesky LJ, Ehrisman JA, 2016. Impact of postoperative nausea and vomiting prophylaxis with dexamethasone on the risk of recurrence of endometrial cancer. Curr Med Res Opin.;32(3):453-8.
Nagelhout, J., Elisha, S. 2018. Nurse Anesthesia. 782-882, 978. Nurok, M. 2017., Dexamethasone and perioperative blood glucose in patients undergoing
total joint arthroplasty. J Clin Anesth. 37:116-122. Sannarangappa V. Inhaled corticosteroids and secondary acute adrenal insufficiency. Open
Respir Med J. 2014; 8:93-100.
Scott NB, McDonald D, Campbell J. 2013. The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units. Arch Orthop Trauma Surg;133(1):117-24.
Sherif AA. Dexamethasone as Adjuvant for Femoral Nerve Block following Knee Arthroplasty: A Randomized, controlled study. Acta Anaesthesiol Scand. 2016; 60(7):977-87.
Venkatesh B. 2018. Adjunctive glucocorticoid therapy in patients with septic shock. NEJM. 1;378(9):797-808.
Vinclair M., 2007. Duration of adrenal inhibition following a single bolus dose of etomidate in critically ill patients, Intensive Care Med. 37-43.
Wakim J., 2006. Anesthetic implications for patients receiving exogenous corticosteroids. AANA Journal, 74(2), 133-139.
Wang Y., 2009. Effects of different glucocorticoids on blood sugar during surgery under general anesthesia. Zhonghua, 89(27),1913-15.
Zorilla-Vaca A., 2018. Dexamethasone injected perineurally is more effective than administration intravenously for peripheral nerve blocks: A meta-analysis of RCT’s. Clin JPain;34(3):276-284
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