Transcript Steroids and Anesthetic Considerations

Steroids and Anesthetic
Considerations
Sass Elisha, CRNA, Ed.D
[email protected]
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WORLDS FAVORITE PHARMACOLOGIST
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REGULATION OF THE HPA AXIS
Stimulation
Inhibition
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Corticotropin-releasing
hormone
Decreased cortisol
Transition from sleep to
awake
Physiologic Stress
Hypoglycemia
Trauma/Sepsis
Alpha and Beta-agonists
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Adrenocorticotropic
hormone (ACTH)
Increased cortisol
General anesthesia
Etomidate
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HPA Axis Suppression
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Patients who have received supraphysiologic
doses of steroids for a period of
___________should be considered to have some
degree of HPA axis impairment during acute stress.
HPA axis dysfunction is dependent on the _____
and ______of steroid therapy.
Who should receive steroids preoperatively?
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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
Various Steroids and Equipotent Dosages
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Hydrocortisone 100 mg
Prednisone 25 mg
Methylprednisolone 20mg
 Dexamethasone
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3.75 mg
Your patient is at risk for acute adrenal crises.
There is no hydrocortisone in the hospital.
What do you do?
Dexamethasone 8 mg is:
A. a lot of steroid, B. a little bit of steroid
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Mechanism of Action of Steroid Hormones
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Acute response occurs in seconds to
minutes and rapidly increases cortisol
production by increasing the supply of
cholesterol substrate.
 Chronic
response occurs over hours to
days and reflects genetic changes that
increases steroidogenic enzymes.
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Cortisol Secretion
Cortisol secretion=Highest in the morning
(20ug/dl)
 Lowest around midnight (5ug/dl)
 Normal daily output of cortisol=_________
 Maximum daily output of cortisol= ______
 Why don’t patients develop adrenal
insufficiency after 8 mg of Decadron?
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Absorption of Exogenous Steroids
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Steroids are given by IV, IM, PO, IA, epidural
routes.
Absorption occurs by; inhalation, mucosal and
skin applications.
Do patients taking steroids via inhalation
or skin routes need preoperative steroids?
Epidural steroids?
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Transport to Tissues
 Cortisol
is 90% bound to cortisolbinding globulin (CBG) and
albumin in the blood
 Only 10% of cortisol is actively
available to exert actions via
intracellular receptors
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Metabolism and Excretion
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In the liver, cortisol undergoes phase 1
oxidation reduction reaction to form
dihydrocortisol and tetrahydrocortisol.
The above metabolites are conjugated to
water soluble substances and excreted
by the kidneys.
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Signs and Symptoms Associated
with Acute Adrenal Crises
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Neurologic
Hemodynamic
Metabolic-Hypog _ _ _ _ _ _ _
Hypov _ _ _ _ _ _
Hypon _ _ _ _ _ _ _
Hyperk_ _ _ _ _ _
Metabolic _ _ _ _ _ _ _ _
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Electrolyte Abnormality Associated
with Acute Adrenal Crises
Acute Adrenal Crises
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 H
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 M
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Treatment of Acute Adrenal Crises
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Hydrocortisone 100 mg IV
Hydrocortisone 200 mg IV infusion over 24 hours
Fluid replacement
Glucose replacement and monitoring
Arterial line placement
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 days
then resume preoperative dosage
Etomidate-Inhibition of Cortisol
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Concerns about Etomidate and
Acute Adrenal Crises
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Higher mortality after Etomidate
administration in patients with
septicemia despite dosage
Alternative drug choices for induction in
critically ill patients?
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MOC-Etomidate
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Soft analogue of Etomidate
Rapid metabolism
No adrenocortical suppression
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Physiologic Effects of
Cortisol/Synthetic Steroids
Redistribution of blood flow to CNS
 Increased cardiac output
 Increased respiratory rate
 Increased gluconeogenesis
 Decreased inflammatory and immune
response
 Enhanced analgesia
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Steroids and Drug Interactions
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Digoxin (inc toxicity, cardiomyopathy)
Barbiturates/phenytoin (dec steroid effects)
Diuretics (hypokalemia)
NSAIDS (stomach ulcers)
Oral anticoagulants (enhanced or
decreased efficacy)
Antidiabetics (decreased effectiveness)
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Got STEROIDS for PONV?
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Decadron most efficacious if given prior to
induction of anesthesia
Decadron most effective with 8 mg dose
Onset 1 h
Peak 8-10 h
Duration 72 h
Should I give 100 mg hydrocortisone for
potential adrenal insufficiency and 8mg
decadron for PONV?
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Steroids and Septic Shock
Sepsis=iNOS
 Increased nitric oxide=vasodilator
 Cytokines decrease #’s/affinity of
glucocorticoid receptors for cortisol
 Surviving sepsis campaign (SSC), 2013
200 mg hydrocortisone if ↓BP after volume
resuscitation and max vasopressors
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IV and perineural dexamethasone
equivalent analgesic duration
Desmet, 2013
Grp A-Interscalene brachial plexus block
(ISB) 0.5% Ropivicaine
 Grp B-ISB 0.5% Ropivicaine +
Decadron 10 mg
 Grp C-ISB 0.5% Ropivicaine +
Decadron 10 mg IV
Analgesic effect of IV Decadron equivalent to
perineural Decadron
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Steroids to Reduce Postoperative Pain
De Oliveira, 2011
Decadron 0.1 mg/kg is effective in reducing
postoperative pain and decreasing opioid
consumption after ambulatory gynecologic
surgery.
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Steroids and Interscalene Nerve Blocks
Cummings, 2011
Grp A-Ropivicane/Bupivicaine 0.5%
 Grp B-Medication above w Decadron 8 mg
Decadron increased time of analgesia from
11-15 h to 23 h postop
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Steroids and Diabetes
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Physiologic stress response
Steroids increase gluconeogenesis
Decadron 10 mg IV significantly increases
blood sugar 180 minutes post injection in
healthy volunteers
Effects greatest in insulin dependent diabetics
Should we give steroids for PONV to patients
with diabetes?
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Steroids and Cancer Risk
Yu, 2015
Intravenous (IV) dexamethasone (4-10 mg)
intraoperatively or postoperatively
Patients who did not receive Decadron had better
three-year survival outcomes as compared with
patients given dexamethasone perioperatively. Our
results indicate that rectal cancer patients treated
with curative surgery may get survival benefit from
avoiding low-dose perioperative dexamethasone.
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Steroids and Postoperative Infection?
Assante, 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 largescale randomized controlled trial is consistently
mentioned.
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Safety and Epidural Steroid Injections
APSF, 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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References
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Boonen E., Reduced cortisol metabolism during critical illness., 2013. NEJM,
1477-1488.
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), 29452952.
Cummings KC., 2011. Effect of dexamethasone on the duration of interscalene
nerve blocks with ropivicaine or bupivicaine,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.
Desmet, M., 2013. IV and perineural dexamethasone are equivalent in increasing
the analgesic duration of a single shot interscalene block with ropivicaine for
shoulder surgery: A prospective randomized placebo study.
BJA, 1-8.
Elisha S, Gabot M, Giron S. 2011. Steroids. In Pharmacology for Nurse
Anesthesiology, Ouelette R, Joyce J, eds. 303-311.
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.
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More
References
Grover V. K., 2007. Steroid therapy-Current indications in practice, Indian
Journal of Anesthesia. 51(5), 389-393.
Jakobsson J., 2010.Preoperative single dose intravenous dexamethasone
during ambulatory surgery. Curr Opin Anesthes. 23, 682-686.
Khan Shariq., 2013. Wound complications and dexamethosone, Anesth &
Analg. 116(5), 965-967.
Legrand M., Plaud, B. 2013. Etomidate and general anesthesia: The
butterfly effect? Anes & Analg, 117(6) 1267-1268.
Marik PE, Varon J. 2008. Requirement of postoperative stress doses of
corticosteroids. Arch Surg. 143(12), 1222-1226.
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.
Wang J.J., 2000. The effect of timing of dexamethasone administration on
its efficacy as a prophylactic antiemetic for postoperative nausea and
vomiting. Anes & Analg, 91, 139-139.
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Yu HC1, Luo YX2, Peng H3, Kang L3, Huang MJ3, Wang JP.Eur J Surg
Oncol. Avoiding perioperative dexamethasone may improve the
outcome of patients with rectal cancer.2015 May;41(5):667-73.
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Assante J, Collins S, Hewer I. Infection Associated With SingleDose Dexamethasone for Prevention of Postoperative Nausea
and Vomiting: A Literature Review. AANA J. 2015
Aug;83(4):281-8.
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