Anesthetic Implications for Patients on Steroids Undergoing

Surgery

Claire Yang, SRNADuke Class of 2013

Case Presentation

Steroid-induced Adrenal Insufficiency

Objectives• Review physiology of the Hypothalamic Pituitary Axis

– specifically glucocorticoid regulation during increased stress as seen in surgery

• Identify the patient population most susceptible to adrenocortical hypofunction.

• Recognition of adrenal suppression and secondary adrenal insufficiency

• Perioperative management of patients treated with glucocorticoids

Hypothalamic-Pituitary-Adrenal (HPA) Axis

Cortisol: Essential for Life

• Cortisol (synthetic form: hydrocortisone)

• Required for vascular and bronchial smooth muscle to be responsive to catecholamines

• Aids in fats, protein, and carbohydrates metabolism

• Blood sugar through gluconeogenesis

• Anti-inflammatory

Cortisol Secretion

• Highest in the morning (20ug/dL)• Lowest around midnight (5ug/dL)• Normal daily output: 10-20mg/day

• General anesthesia and surgery: 150 mg/day

Activate HPA

Cortisol

Surgical stress

Trauma Sepsis

Hypoglycemia

Hypothalamic-Pituitary-Adrenal (HPA) Axis in Healthy People

Stoelting’s, 5th ed

• Addison’s dx• Normal ACTH• Destruction of

adrenal cortex

1° Adrenal Insufficiency

• ACTH • Pituitary

surgery/irradiation• Chronic synthetic

glucocorticoid use

2° Adrenal Insufficiency

Biochemical Diagnosis of Adrenal Insufficiency

ACTH-stimulation test• Withhold exogenous steroids x24 hrs*• Baseline cortisol level• IV synthetic ACTH 250ug• ✓ Cortisol level at 30 and 60 minutes later• A cortisol level < 20 μg/dL at any time point

shows adrenal insufficiency

Adrenal insufficiency: S/S

• Fatigue, weakness, anorexia• Nausea and vomitting• Hypotension• Hypovolemia• Hyponatremia• Hyperkalemia

Acute adrenal crisis circulatory collapse

• Rheumatoid arthritis• COPD Exacerbation• Asthma Flare• Crohn’s ds• Low Back Pain

Common Chronic Conditions Treated with Glucocorticoids

• Head Trauma• Recent Use of Etomidate

Trauma

Patient Populations Potentially at Risk for HPA axis Suppression

All Kinds of Formulation

• Oral• IV• Inhaler• Topical ointment/creams• Intra-articular injections for arthritis • Epidural injections for lumbar disk pain • Eye drops• Nasal spray

Benefits Adverse Effects

Osteoporosis

Decreased immune response

Steroids-induced diabetes

Hypertension

Avoid Vascular Collapse

Maintain Homeostasis

Adverse Effects of Glucocorticoids

• Hypertension• Glucocorticoid-induced Diabetes• Decreased immune response• Osteoporosis• Peptic ulcer disease• Fatty liver

Supra-physiologic Dosing

• > 7.5mg Prednisone per day or its equivalent

• Cushingoid appearance

• Hypothalamic-pituitary-adrenal suppression

• Adrenal suppression: cortisol production

• When discontinued abruptly: risk for Adrenal insufficiency

Cleveland Clinic J Med, 78(11), 748-756

Various Steroids and Equipotent Doses (Oral or IV)

Adrenal Suppression with Exogenous Steroids

Adrenal Suppression secondary to corticosteroid therapy depends on multiple factors:• Dose• Duration• Frequency• Time• Route of

Administration

Clinical Relevance

• Onset: as early as 1 week after starting corticosteroid therapy

• Recovery: can take from 2 weeks to 6-12 months

Management of Anesthesia for Patients Treated with Glucocorticoids

• No specific anesthetic agents and/or technique are recommended in managing patients with or at risk for adrenal insufficiency

Who should receive steroid cover for surgery?

Suppressed HPA Axis

Patients receiving > 20mg/day of

prednisone for greater than 3 weeks

Any patient on glucocorticoids with Cushing’s appearance

Intermediate Patients

Patients on doses of 5mg/day to 20mg/day

Patients have variability in HPA axis suppression• Dependent on age, sex,

dose, duration of therapy

Consider evaluation of HPA axis suppression

by way of morning serum cortisol or ACTH

stimulation tests

Intra-Articular and Spinal Glucocorticoid

Injections

HPA axis suppression has been reported

Factors include dose, interval and number of

glucocorticoid injections

Suggest testing of HPA axis suppression in

patients receiving > 3 injections

(Hamrahian, Roman, & Milan, 2012)

Hydrocortisone (Solu-Cortef) Supplementation

Local anesthesia No supplementTake usual AM dose

Minor (inguinal hernia repair)

+ 25mg IV

Moderate(cholecystectomy, total joint, hysterectomy)

+ 50-75mg IV taper 1-2 days

Major(Cardiac, liver, whipple)

+ 100-150mg IV taper 1-2 days

Salem et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg 1994; 219: 416-25

Hamrahian, A., Roman, S., & Milan, S. (2012)

Treatment of Acute Adrenal Crisis

Treatment of Acute Adrenal Crisis

• Hydrocortisone 100mg IV• Hydrocortisone 10mg/hr x 24 hrs• Fluid replacement (D5 NS)• Glucose replacement and monitoring• Arterial line placement/ABG• Vasopressor and inotropic support

Conclusion and Further Research

• Adrenal hormones are essential for life. Too much or too little can be dangerous

Conclusion and Further Research

• It appears, within the literature, at the very least, patients should receive their steroid regimen leading up to surgery

Conclusion and Further Research

• Those who miss doses, should be considered at risk

• Administering supplemental steroids should be considered based on the type and duration of the surgery

Conclusion and Further Research

• Furthermore, the benefit of administering steroids outweighs the risk or consequences of steroid administration

References• Axelrod, L. (2003). Perioperative management of patients treated with

glucocorticoids. [Review]. Endocrinol Metab Clin North Am, 32(2), 367-383

• Hamrahian, A., Roman, S., & Milan, S. (2012, August). The Surgical Patient Taking Glucocorticoids. Retrieved from www.UpToDate.com

• Lansang, M. C., & Hustak, L. K. (2011). Glucocorticoid-induced diabetes and adrenal suppression: how to detect and manage them. [Review]. Cleve Clin J Med, 78(11), 748-756. doi: 10.3949/ccjm.78a.10180

• Pavlaki, A., Magiakou, M., Chrousos, G. (2011). Chapter 13: Adrenal insufficiency. Retrieved from www.endotext.org

• Salem, M., Tainsh, R. E., Jr., Bromberg, J., Loriaux, D. L., & Chernow, B. (1994). Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. [Review]. Ann Surg, 219(4), 416-425.

References• Wakim, J. H., & Sledge, K. C. (2006). Anesthetic implications for patients

receiving exogenous corticosteroids. [Review]. AANA J, 74(2), 133-139

• Welsh, G., Manzull, E., Nieman, L. (2007). The surgical patients taking glucocorticoids. UpToDate. Retrieved from www.UpToDate.com