Perioperative Steroids

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PERIOPERATIVE STEROIDS

Dr.Srikanth/Dr.Venkatesh


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Introduction

Widely used group of drugs in anaesthesiapractice.

Glucocorticoids protect against stress andproduce an anti-inflammatory response in thebody.

Cortisol also known as hydrocortisone, is themost potent glucocorticoid.


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Functions of cortisol include maintenance of cardiac function,systemic blood pressure, andnormal responses to catecholamines.

Cortisol also regulates the metabolism of fats,

carbohydrates, and proteins and balancessodium and potassium levels.


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Physiology


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Circadian secretion of cortisol


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Contd.. GLUCO CORTICOIDS

Control the blood sugar levels by burning fat andproteins, in response to stress or injury.

MINERALO CORTICOIDSThese control blood volume, regulate bloodpressure.

They regulate R-A-A system , control release of angiotension II.They regulate Na + , K+ excretion.


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HPA axis The HPA axis is a physiologic mechanism.

When the body undergoes stress, hypoglycemia,septicemia,trauma and stress from anesthesia and surgery thehypothalamus is stimulated to produce CRH.

CRH stimulates the anterior pituitary to produce ACTH, which, inturn, stimulates the adrenal cortex to synthesize glucocorticoids.

Through an innate negative feedback mechanism, adrenalglucocorticoids regulate the release of CRH and ACTH.

This negative feedback mechanism is known as HPA axis.


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In normal patients with major stresses liketrauma or surgery the HPA axis is activated,leading to a surge in systemic cortisol.

This surge continues for up to 72 hours after the insult

Protective as cortisol has a number of anti-inflammatory effects and preventshypotension and shock.


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Cortisol production Baseline cortisol production is approximately

10 mg/day (range 5-25).J Clin Endocrinol Metab 2001;86:5920-4.

Normal individuals produce 75 to 150 mg/dayof cortisol in response to major surgical stress,50mg/day for minor surgery.

They rarely produce more than 200 mg in the24 hours after major surgery.


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Disease states that normally require long-termcorticosteroid use include rheumatoid arthritis,Crohn disease and bronchial asthma.

Rheumatoid arthritis and Crohn disease oftenrequire surgical procedures to treat the diseaseitself.

Asthma does not require surgery for relief, butpatients with this disease often undergo surgicalprocedures.


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Patients receiving long- term corticosteroidtreatment have suppression of the HPA axis , withthe adrenal gland shown to become atrophic.

Adrenal glands cannot function properly underthe stress of surgery in which there is a need formore cortisol.

Loss of this surge may precipitate intraoperativeor postoperative haemodynamic instability.


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Who needs replacement therapy ??

Patients receiving long-term corticosteroidtherapy

long term steroids equivalent to more than10mg prednisolone daily (or who havereceived such a dose within the last 3months).


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Patients currentlytaking steroids

< 10 mg/day Assume normalHPA response

Additonal steroidcoverage notrequired

> 10 mg/day

Minor surgery(eg:inguinal hernia

repair)

25 mg of hydrocortisone @

induction

Moderate surgery(eg:nonlaparoscopiccholecystectomy,total jointreplacement,abdominal

hysterectomy)

Usual preoperativesteroids+25 mg of hydrocortisone@ induction

+ 100 mg/day for24 h

Major surgery(eg:cardiacsurgery,totalproctocolectomy,cardiopulmonaryb ass

Usual preoperativesteroids+25 mg of hydrocortisone@ induction

+ 100 mg/day for48h-72 h.


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Patientsstopped

takingsteroids

< 3 months Treat as if they are on

steroids> 3 months No

additionalcoverage


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Recommended tapered doses of hydrocortisone

Post op day Recommended dose

DAY 1 Hydrocortisone, 100 mg, every 8 hstarting with induction of anesthesia

DAY 2 Hydrocortisone, lower dose to 50 mgevery 8 h if patient is in stable conditionand major postoperative stress is resolved

DAY 3 Hydrocortisone, 25 mg every 8 h

DAY 4 Hydrocortisone, 25 mg twice per day

DAY 5 Hydrocortisone maintenance dose: 15-20mg in the morning and 5-10 mg in theevening


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An infusion is preferable as it avoids largeincreases caused by bolus injection.

If there is any practical difficulties, one quarterof the daily dose can be given sixth hourly.

Hydrocortisone can safely be added to 5%Dextrose, Normal Saline & Dextrose Saline.


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High doseimmunosupression

Give usualimmunosupressive dosesduring peri operative

period

Eg: patient who is taking 60 mg prednisolone per dayrequires 250mg hydrocortisone infusion over 24 hoursduring perioperative period till oral intake isestablished.


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Anti inflammatory

These can prevent or suppress inflammationradiation, mechanical, chemical, infectiousand immunological stimuli.

Supress both humoral and cell mediatedimmunity.


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Mechanisms Inhibit the production of interluekins, cytokines,

chemotatic agents. Decreased release of vasoactive and chemo

attractive factors Diminished secretion of lipolytic and proteolytic

enzymes Decreased extravasation of luecocytes to area of

injury Resulting in diminished inflammatory response.


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For their anti-inflammatory actions common perioperativeindications are :

(a) Hyper-reactive airways: asthma, foreign body, and trauma.

(b)Anaphylactic reactions: drug allergies, blood transfusionreactions.

(c)Transplantation of solid organs.

(d) Spinal cord injuries (within 8 hours of injury).


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Hyper reactive airway By virtue of their anti-inflammatory action.

Decreased mucosal edema.

prevention of release of bronco-constrictingsubstances.

They are useful in acute and chronic hyperreactive airways


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Can be used orally, parenterally or aerosolform.

Hyper-reactive states in anaesthetic practiceare patients with h/o asthma, recent URTI,difficult airway, multiple intubation attempts,aspiration, foreign body bronchus, airwaysurgeries and COPD.


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PONV

Is thought to be due to decrease in productionof inflammatory mediators which are knownto act on the CTZ area as well as improve the

blood-brain barrier function.

They act synergistically 5 HT3 antagonists.

10mg of DEXAMETHASONE at the time of induction.


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Steroids and analgesia Various routes of administration of steroids

include parentral, local infiltration at operatedsite, as an adjuvant in nerve blocks and central-neuraxial blockade.

The commonly used steroid is hydrocortisone100-125mg day.

Mode of analgesia-Anti inflammatory action,major role in decreasing amplifying andmaintenance of pain perception.


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STEROIDS AND SEPSIS/SEPTIC SHOCK

Patients having severe sepsis or in septic shockmay have occult or unrecognized adrenalinsufficiency,

Incidence may be as high as 28% in seriously illpatients.

Clinically, in sepsis with adrenal insufficiency,steroid supplementation was associated withsignificantly higher rate of success in thewithdrawal of vasopressin therapy.


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Steroids in day care surgery Decrease the incidence

Of PONV,postoperative pain.

Establish early oral intake,

Produce euphoric effect by decreasing level of

prostaglandins,

Elevate endorphin levels.


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Other uses

Spinal cord injury: Suggested protocol in spinal cord injury is high

dose methyl prednisolone with an intravenous

bolus dose of 30mg/kg followed by 5.4mg/kg/hrinfusion for 23hours.

Steroids must be used within 8 hrs of cord insultto be of any benefit.


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Cerebral edema:

Have a role in reduction or prevention of edema associated with parasitic infections andneoplasms.


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Adverse effects

Hyperglycemia. Immunosupression Protein catabolism Impaired wound healing Hypertension Fluid overload Psychosis Aseptic necrosis of femoral head.


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Conclusion

Certain diseases require long term steroidtherapy

Thorough preoperative history regardingprevious medications should be taken

Determine who is at risk for adrenal crisis.


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To provide safe anesthesia, anesthesiaproviders must be aware of the functions of cortisol and choose the best perioperative

replacement regimen available.

There should be a protocol that includes notonly replacement of corticosteroids at surgerybut also tapering the corticosteroids aftersurgery.


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When taking oral corticosteroids longer term, you mayexperience:

Clouding of the lens in one or both eyes (cataracts) High blood sugar, which can trigger or worsen diabetes Increased risk of infections Thinning bones (osteoporosis) and fractures Suppressed adrenal gland hormone production Thin skin, easy bruising and slower wound healing


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REFERENCES:

Indian Journal or Anaesthesia 2007 Steroid Therapy Current Indications in Practice

Update in Anaesthesia Guidelines for Perioperative steroids


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Perioperative Steroids

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