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1/9/2016 1 Steroids and Anesthetic Considerations Sass Elisha, CRNA, Ed.D [email protected].

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06/21/22 1 Steroids and Anesthetic Considerations Sass Elisha, CRNA, Ed.D [email protected]
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Page 1: 1/9/2016 1 Steroids and Anesthetic Considerations Sass Elisha, CRNA, Ed.D sass.m.elisha@kp.org.

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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.

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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.


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