1/9/2016 1 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 Corticotropin-releasing
hormone 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 Suppression 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
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Various Steroids and Equipotent Dosages
Hydrocortisone 100 mg Prednisone 25 mg Methylprednisolone 20mg
Dexamethasone 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
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
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 cortisol-
binding 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 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.
Signs and Symptoms Associated with Acute Adrenal Crises
Neurologic Hemodynamic Metabolic-Hypog _ _ _ _ _ _ _
Hypov _ _ _ _ _ _
Hypon _ _ _ _ _ _ _
Hyperk_ _ _ _ _ _
Metabolic _ _ _ _ _ _ _ _
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Electrolyte Abnormality Associated with Acute Adrenal Crises
Acute Adrenal Crises H H H M
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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 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 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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MOC-Etomidate
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 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? Decadron most efficacious if given prior to
induction of anesthesia Decadron most effective with 8 mg dose1. Onset 1 h
2. Peak 8-10 h
3. 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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Steroids to Reduce Postoperative PainDe 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 BlocksCummings KC, 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 with Decadron postop
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Steroids and Diabetes 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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References 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), 2945-2952.
Cotton B. A., 2008. Increased risk of adrenal insufficiency following etomidate exposure in critically injured patients, Arch Surg. 143(1), 62-67.
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.
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.