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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