PERIOPERATIVE STEROIDS

Dr.Srikanth/Dr.Venkatesh

Introduction
Widely used group of drugs in anaesthesia practice. Glucocorticoids protect against stress and produce an anti-inflammatory response in the body.

Cortisol also known as hydrocortisone, is the most potent glucocorticoid.

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

Cortisol also regulates the metabolism of fats, carbohydrates, and proteins and balances sodium and potassium levels.

Physiology

Circadian secretion of cortisol

Contd..
GLUCO CORTICOIDS Control the blood sugar levels by burning fat and proteins, in response to stress or injury.

MINERALO CORTICOIDS These control blood volume, regulate blood pressure. They regulate R-A-A system , control release of angiotension II. They regulate Na+ , K+ excretion.

HPA axis
The HPA axis is a physiologic mechanism. When the body undergoes stress, hypoglycemia, septicemia,trauma and stress from anesthesia and surgery the hypothalamus is stimulated to produce CRH.

CRH stimulates the anterior pituitary to produce ACTH, which, in turn, stimulates the adrenal cortex to synthesize glucocorticoids.
Through an innate negative feedback mechanism, adrenal glucocorticoids regulate the release of CRH and ACTH. This negative feedback mechanism is known as HPA axis.

Indications
1) Perioperative replacement therapy. 2) Anti-inflammatory uses and hyper-reactive airway. 3) Post-operative nausea and vomiting(PONV). 4) Analgesia adjunct. 5) Day care surgery. 6) Anaphylaxis. 7) Septic shock. 8) Others- cerebral edema, spinal cord injury.

 In normal patients with major stresses like trauma 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 antiinflammatory effects and prevents hypotension and shock.

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/day of cortisol in response to major surgical stress, 50mg/day for minor surgery.

They rarely produce more than 200 mg in the 24 hours after major surgery.

 Disease states that normally require long-term corticosteroid use include rheumatoid arthritis, Crohn disease and bronchial asthma. Rheumatoid arthritis and Crohn disease often require surgical procedures to treat the disease itself.

Asthma does not require surgery for relief, but patients with this disease often undergo surgical procedures.

 Patients receiving long- term corticosteroid treatment have suppression of the HPA axis, with the adrenal gland shown to become atrophic. Adrenal glands cannot function properly under the stress of surgery in which there is a need for more cortisol.

Loss of this surge may precipitate intraoperative or postoperative haemodynamic instability.

Who needs replacement therapy ??

Patients receiving long-term corticosteroid therapy long term steroids equivalent to more than 10mg prednisolone daily (or who have received such a dose within the last 3 months).

EQUIVALENT DRUG DOSES

Betamethasone 1.5 mg Cortisone acetate 50 mg Prednisolone 10 mg is equivalent to Dexamethasone 1.5 mg

Hydrocortisone 40 mg
Deflazacort 12mg Methylprednisolone 8 mg

< 10 mg/day

Assume normal HPA response Minor surgery (eg:inguinal hernia repair)

Additonal steroid coverage not required 25 mg of hydrocortisone @ induction

Patients currently taking steroids

> 10 mg/day

Usual preoperative Moderate surgery steroids (eg:non +25 mg of laparoscopic hydrocortisone cholecystectomy,tot @ induction al joint + 100 mg/day for replacement,abdo 24 h minal hysterectomy) Major surgery (eg:cardiac surgery,total proctocolectomy,ca rdiopulmonary bypass)

Usual preoperative steroids +25 mg of hydrocortisone @ induction + 100 mg/day for 48h-72 h.

Patients stopped taking steroids

< 3 months Treat as if they are on steroids > 3 months No additional coverage

Recommended tapered doses of hydrocortisone

Post op day DAY 1 Recommended dose Hydrocortisone, 100 mg, every 8 h starting with induction of anesthesia Hydrocortisone, lower dose to 50 mg every 8 h if patient is in stable condition and major postoperative stress is resolved Hydrocortisone, 25 mg every 8 h Hydrocortisone, 25 mg twice per day Hydrocortisone maintenance dose: 15-20 mg in the morning and 5-10 mg in the evening

DAY 2

DAY 3 DAY 4 DAY 5

 An infusion is preferable as it avoids large increases caused by bolus injection. If there is any practical difficulties, one quarter of the daily dose can be given sixth hourly.

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

High dose immunosupression

Give usual immunosupressive doses during peri operative period

Eg: patient who is taking 60 mg prednisolone per day requires 250mg hydrocortisone infusion over 24 hours during perioperative period till oral intake is established.

Anti inflammatory
These can prevent or suppress inflammation radiation, mechanical, chemical, infectious and immunological stimuli. Supress both humoral and cell mediated immunity.

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.

 For their anti-inflammatory actions common perioperative indications are : (a) Hyper-reactive airways: asthma, foreign body, and trauma.

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

(c)Transplantation of solid organs. (d) Spinal cord injuries (within 8 hours of injury).

Hyper reactive airway

By virtue of their anti-inflammatory action. Decreased mucosal edema.

prevention of release of bronco-constricting substances. They are useful in acute and chronic hyper reactive airways

 Can be used orally, parenterally or aerosol form. Hyper-reactive states in anaesthetic practice are patients with h/o asthma, recent URTI, difficult airway, multiple intubation attempts, aspiration, foreign body bronchus, airway surgeries and COPD.

PONV
Is thought to be due to decrease in production of inflammatory mediators which are known to 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.

Steroids and analgesia

Various routes of administration of steroids include parentral, local infiltration at operated site, as an adjuvant in nerve blocks and centralneuraxial blockade.

The commonly used steroid is hydrocortisone 100-125mg day. Mode of analgesia-Anti inflammatory action, major role in decreasing amplifying and maintenance of pain perception.

STEROIDS AND SEPSIS/SEPTIC SHOCK

Patients having severe sepsis or in septic shock may have occult or unrecognized adrenal insufficiency, Incidence may be as high as 28% in seriously ill patients. Clinically, in sepsis with adrenal insufficiency, steroid supplementation was associated with significantly higher rate of success in the withdrawal of vasopressin therapy.

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.

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/hr infusion for 23hours. Steroids must be used within 8 hrs of cord insult to be of any benefit.

Cerebral edema: Have a role in reduction or prevention of edema associated with parasitic infections and neoplasms.

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

Conclusion
Certain diseases require long term steroid therapy Thorough preoperative history regarding previous medications should be taken

Determine who is at risk for adrenal crisis.

 To provide safe anesthesia, anesthesia providers must be aware of the functions of cortisol and choose the best perioperative replacement regimen available. There should be a protocol that includes not only replacement of corticosteroids at surgery but also tapering the corticosteroids after surgery.

 When taking oral corticosteroids longer term, you may experience: 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

REFERENCES:
Indian Journal or Anaesthesia 2007
Steroid Therapy Current Indications in Practice

Update in Anaesthesia
Guidelines for Perioperative steroids

THANK YOU