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Anesthetic Implications for Patients on Steroids Undergoing
Surgery
Claire Yang, SRNADuke Class of 2013
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Case Presentation
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Steroid-induced Adrenal Insufficiency
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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
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Hypothalamic-Pituitary-Adrenal (HPA) Axis
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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
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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
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Activate HPA
Cortisol
Surgical stress
Trauma Sepsis
Hypoglycemia
Hypothalamic-Pituitary-Adrenal (HPA) Axis in Healthy People
Stoelting’s, 5th ed
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• Addison’s dx• Normal ACTH• Destruction of
adrenal cortex
1° Adrenal Insufficiency
• ACTH • Pituitary
surgery/irradiation• Chronic synthetic
glucocorticoid use
2° Adrenal Insufficiency
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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
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Adrenal insufficiency: S/S
• Fatigue, weakness, anorexia• Nausea and vomitting• Hypotension• Hypovolemia• Hyponatremia• Hyperkalemia
Acute adrenal crisis circulatory collapse
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• 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
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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
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Benefits Adverse Effects
Osteoporosis
Decreased immune response
Steroids-induced diabetes
Hypertension
Avoid Vascular Collapse
Maintain Homeostasis
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Adverse Effects of Glucocorticoids
• Hypertension• Glucocorticoid-induced Diabetes• Decreased immune response• Osteoporosis• Peptic ulcer disease• Fatty liver
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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
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Various Steroids and Equipotent Doses (Oral or IV)
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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
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Management of Anesthesia for Patients Treated with Glucocorticoids
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• No specific anesthetic agents and/or technique are recommended in managing patients with or at risk for adrenal insufficiency
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Who should receive steroid cover for surgery?
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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)
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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
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Hamrahian, A., Roman, S., & Milan, S. (2012)
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Treatment of Acute Adrenal Crisis
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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
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Conclusion and Further Research
• Adrenal hormones are essential for life. Too much or too little can be dangerous
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Conclusion and Further Research
• It appears, within the literature, at the very least, patients should receive their steroid regimen leading up to surgery
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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
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Conclusion and Further Research
• Furthermore, the benefit of administering steroids outweighs the risk or consequences of steroid administration
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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.
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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