Why corticosteroids have to be withheld prior to surgery?

Advance PathophysiologyN 204 Group 3

CAMINCE, AILYN ORBETA CAPITO, JAYNE PETRICIA MILLAREZ CARAVEO, MARY LORELEI CASILAO, SHERRY LYN MOJICA CASTILLO, ANA JURY HERNANDEZ CASTRO, VICTORINA MANGIBUNONG CEREZO, MELANIE SAYABOC CISCAR, ABIGAIL CONANAN COBANGBANG, ANTHONY COLENDRES, CHARMAINE ASENCIO CRUZ, KATHLEEN ROSE ROSAL CRUZ, KATRINA BELBIS DAILEG, ANNALIZA AROLA DAZA, MA. BERNADETTE CRUZ DE JESUS, GAYZELL ALMIRAÑEZ DE VEYRA, ANNABELLE MONTEJO DELA CRUZ, SHIELISSE RAMOS

Date Submitted : 26 June 2011 Submitted To: Professor Rita Ramos

How we come up with the answers

Pharmacology : Corticosteroid

ActionsImportant to distinguish between physiological effects (replacement therapy) and pharmacological effects (occur at higher doses)

Mineralocorticoid Na retention by renal tubule increased K excretion in urine

Glucocorticoid CHO metabolism: increased gluconeogenesis, ± peripheral glucose

uptake may be decreased with resultant hyperglycaemia ± glycosuria

protein metabolism: anabolism is decreased but catabolism continues unabated or is increased resulting in negative N balance and muscle wasting. Osteoporosis occurs, growth slows in children, skin atrophies (together with increased capillary fragility leads to bruising and striae), healing and fibrosis delayed

fat deposition: increased on shoulders, face and abdomen inflammatory response depressed allergic response depressed antibody production reduced by large doses lymphoid tissue reduced (including leukaemic lymphocytes) decreased eosinophils renal urate excretion increased euphoria or psychotic states may occur. ? due to CNS electrolyte

changes anti-vitamin D action reduction of hypercalcaemia (chiefly where this is due to increased

absorption from gut: vit D intoxication, sarcoidosis) increased urinary Ca excretion. Renal stones may form growth reduction where new cells are being added (eg in children)

but not where they are replacing cells as in adult tissues suppression of HPA axis. NB steroid suppressed adrenal continues

to secrete aldosterone

prednisolone is standard choice for anti-inflammatory therapy. Can be given orally or IM

methylprednisolone used for IV pulsed therapy dexamethasone longer acting. fludrocortisone used to replace aldosterone where the

adrenal cortex has been destroyed beclomethasone and budesonide used by inhalation for

asthma. About 90% of inhalation dose is swallowed and inactivated by first-pass hepatic metabolism (steroids listed above are protected from this by protein binding). The rest, which is absorbed from the mouth and lungs gives very low systemic plasma concentrations. Although risk of HPA axis suppression is very low it can happen.

If the patients maintenance dose exceeds recommended dose to cover surgical stress there is no evidence that any dose alteration is necessary and patient should continue to receive maintenance dose over the perioperative period.

In the case of perioperative complications continued glucocorticoid administration consistent with the postoperative stress response is appropriate

Individual steroids

Treatment of intercurrent illness

CONCEPTS learned

Concept : Stress (Adaptive and Regulatory Mechanism : Unit 1)

Constancy of the Internal Environment

Homeostasis / Self-Regulating Process

Negative / Feedback Mechanism

Stress Adaptation in Disease Causation

With a good balance, homeostasis prevails

Disruption of Equilibrium leads to a disease process

On-going , continuous process to vigilantly maintaining normal physiologic parameters

Increase magnitude and Duration of stress may lead to Death

Disease occurs when a process is unable to adapt well to the Intrinsic and Extrinsic Factors interplaying in Disease Causation

Body Cells need \oxygen, \nutrition, Environment that provides narrow range of temperature, water, acidity and salt concentration

Stress Are stimuli affecting life processes and alters a persons

adaptation / development Yes, Stress response acts to protect the body.

Unfortunately, even for its natural, protective, adaptive characteristics;

There are individual differences in response to stress limit in its ability to compensate

There are individual differences in response to stressors

Increase Magnitude / Duration of stress may result to DEATH

CORTICOSTEROIDS produce synthetic hormones (cortisol) attack tissue decrease inflammatory causing substances block WBC produce by immune cells suppressing inflammation INFLAMMATION Stimulus (tissue damage/injury from surgery) cellular stage WBC (leukocytes) adhere to vessel wall process emigration, leukocytes squeeze through wall and move into the injured tissue leukocytes wander around the tissue and guided by chemical subsance called chemotaxis leukocytes culminates by engulfing the bacteria (phagocytosis) exudates (product of phagocytosis) which accumulates eventually will heal With the presented paradigm of corticosteroids and inflammation it can be clearly seen that corticosteroids should be withheld

prior surgery so that the body will have enough WBC’s in fight for the risk of infection and wound healing from surgery. In addition, it is withheld prior surgery due to the reason that these drugs half life is 1-2 days.

Related Articles

The surgical patient taking glucocorticoids

INTRODUCTION — Chronic glucocorticoid therapy can suppress the hypothalamic-pituitary-adrenal (HPA) axis and, during times of stress such as surgery, the adrenal glands may not respond appropriately. Protocols for "stress dose" steroids followed reports in the 1950s of possible surgery-associated adrenal insufficiency due to sudden preoperative withdrawal of glucocorticoids. However, recent studies have questioned both the need for and current dosage regimens of supplemental perioperative glucocorticoids

Impaired Wound Healing : Increased friability of skin, superficial blood vessels, and other tissues (eg, mild pressure may cause hematoma or skin ulceration, removing adhesive tape may tear the skin, and sutures may tear the gut wall)

Increased risk of fracture, infections, gastrointestinal hemorrhage, or ulcer [5,6]. (See "Major side effects of systemic glucocorticoids".

CORTISOL SECRETION DURING STRESS — Acute physical or psychological stress activates the HPA axis, resulting in

increased plasma corticotropin (ACTH) and serum cortisol concentrations. Stress exerts its effects by stimulating the

hypothalamus to release ACTH secretagogues, with corticotropin- releasing hormone (CRH) and arginine vasopressin

(AVP) being the most important [7,8]. (See "ACTH and cortisol secretion in health and disease".)

Surgery is one of the most potent activators of the HPA axis. Plasma ACTH concentrations increase at the time of

incision and during surgery, but the greatest ACTH and cortisol secretion occurs during reversal of anesthesia,

extubation, and in the immediate postoperative recovery period, primarily it appears, in response to pain [9,10]. The

response is mediated by afferent nerve impulses, since it can be abolished by interrupting the neural connections from

the operative site, such as by sectioning the spinal cord [11], epidural anesthesia [12], or local anesthesia. The plasma

ACTH and serum cortisol responses to surgery can also be reduced by opiate drugs [10,13].

There is considerable variation in the increase in cortisol secretion among individuals undergoing surgery; this variability

is in part due to concomitant medication use, age, and concurrent illness. In general, the adrenal gland produces about

50 mg/day of cortisol during a minor procedure or surgery (normal basal secretion is 8 to 10 mg/day), while 75 to 100

mg/day are produced with major surgery [14]. The cortisol secretion rate can reach 200 to 500 mg/day with severe

stress, but secretion rates greater than 200 mg/day in the 24 hours after surgery are rare [2].

Effect of exogenous glucocorticoids — Both endogenous and exogenous glucocorticoids exert negative feedback

control on the HPA axis by suppressing CRH secretion and, consequently, ACTH secretion. This leads to adrenal atrophy

and loss of cortisol secretory capability.

Patients who are taking glucocorticoids should be monitored carefully for infection postoperatively, because glucocorticoids may suppress the fever response.

Perioperative Medication Management (2008)

An article by Nafisa K. Kuwajerwala. "The time to recovery of normal adrenal function after stopping corticosteroids varies from a few days to several months. The best plan is to assume that patients receiving corticosteroids within 3 months of surgery have some degree of HPAA (hypothalamic-pituitary-adrenal axis) suppression and should receive perioperative supplementation.”

Precautions for Patients on Steroids Undergoing Surgery

Since the 1940s synthetic corticosteroids (or steroids) have been developed for their anti-inflammatory and immunomodulatory effects. Patients on steroids who present for surgery may be at increased risk of complications because of:

The adrenal suppression caused by steroid therapy.1 This often poses the greatest risk and deserves particular attention. It is important for patients to be educated about the risk.2 Steroid cards should be carried by patients taking steroids.

The disease or condition which required them to take steroids. Corticosteroids are used in a wide variety of conditions. Some of these may also have attached risks for anaesthesia (those for example affecting lungs, neck joints or drug metabolism).

Long term and other side effects of steroid therapy. These include: Hypertension Diabetes mellitus Fatty liver Susceptibility to infection Osteoporosis Avascular necrosis of bone Skin sepsis Electrolyte disturbance:hypokalaemia, metabolic alkalosis

There are pre-operative, per-operative and post-operative factors to be considered when assessing and managing these risks.

The risk of adrenal suppression

In normal healthy patients there is a prompt secretion of cortisol with the onset of surgery and secretion remains elevated for several days after surgery. Glucocorticoids are not stored and must be synthesized when required, for example during and after surgery. This response depends on the hypothalamopituitary axis which may be suppressed or unresponsive to stress when steroids have been taken.1 Failure of cortisol secretion may result in the circulatory collapse and hypotension characteristic of a hypoadrenal or 'Addisonian' crisis.2

Pre-operative considerations. How much steroid has been taken and for how long? The degree of adrenal

suppression depends on the dose and duration of steroid treatment. However the integrity of the adrenal response is not routinely tested and steroid cover or supplements are given according to the surgical stimulus (minor, moderate and major surgery).

Dosages of less than 5 mg prednisolone per day are not significant and no steroid cover is required.

10 mg/day or more of prednisolone (or equivalent) is generally taken as the threshold dose for 'steroid cover'.

Steroid cover is required if taken within 3 months of the surgery. This is because adrenal suppression can occur after only a week and may take as long as 3 months to recover.3

Pre-operative considerations. Normal cortisol secretion is about 30 mg/day. The normal rise in

plasma ACTH and hence cortisol is in response to the severity of

surgery. The adrenals are capable of secreting about 300 mg/day (equivalent to about 75 mg of prednisolone) but output

rarely exceeds 150 mg of cortisol/day even in response to

major surgery. Post-operative considerations. The

normal rise in cortisol secretion after surgery lasts about 3 days. In recent years doses used for steroid cover have been reduced4 because

excessive doses cause adverse effects such as post-operative

infection, gastrointestinal haemorrhage and

delayed wound healing.

Pre-operative assessment

This should focus on the history of steroid usage, routine examination (including blood pressure) and basic investigations including:

FBC. U and Es. Blood glucose Liver function tests Investigation for adrenal suppression is rarely done.1 It is possible to

assess this6 with: Serum and urinary cortisol Short synacthen test (SST) - more popular but interpret with care.6 Insulin tolerance test CRH measurement

Peri-operative management

It is useful to summarize who should receive steroid cover for surgery (and during major illness):

Patients on corticosteroids at a dose of 10 mg or more of prednisolone (or equivalent) daily (equivalent to Betamethasone 750 micrograms, Fluticasone 375 micrograms, Dexamethasone 6 mg, Hydrocortisone 20 mg, Methylprednisolone 4 mg daily).

Patients who have received corticosteroids 10 mg daily within the three months preceding surgery.

Patients on high dose inhaled corticosteroids (for example beclomethasone 1.5 mg a day).

Patients who stopped their steroids more than 3 months ago or who are taking 5 mg or less require no steroid cover.

Peri-operative steroid cover

Note that infusion is now preferred to bolus (this avoids excessive doses of steroid with possible complications). Historically doses were even higher, further revision of doses may be recommended with further research, but for the moment empirical recommendations4 are:

Minor surgery - 25 mg hydrocortisone at induction of anesthesia and then resume normal medication postoperatively.

Moderate surgery - Usual dose of steroids pre-operatively and then 25 mg of hydrocortisone intravenously at induction followed by 25 mg IV every 8 hours for 24 hrs. Usual pre-operative dose then continued.

Major surgery - Usual dose of steroids pre-operatively, then a bigger 50 mg of hydrocortisone intravenously at induction followed by 50 mg Intravenously every 8 hours for 48-72 hrs. Continue this infusion until the patient has started light eating, then restart normal pre-operative dose.

Remember that patients receiving <10 mg of prednisolone or equivalent do not need steroid cover but should continue with their usual maintenance steroid dosage. Patients on long term steroids do not require supplementary steroid cover for routine dentistry or minor surgical procedures under local anaesthesia.7

The risk of underlying disease

There is a wide range of diseases for which corticosteroid treatment is commonly used. It is important to remember that these conditions may also carry risk for both anaesthesia and surgery. Examples of conditions likely to have a consequence for surgery and anaesthesia include:

Asthma Rheumatoid arthritis Glomerulonephritis Idiopathic thrombocytopenic purpura Cerebral oedema Malignancies and chemotherapy These conditions should be fully assessed pre-operatively.

Surgery. Surgery is known to cause increased plasma corticosteroid levels during and after operations, with plasma cortisol levels reaching their peak (twofold to 10-fold above baseline) between four and 10 hours after surgery.27,28 The level of response is based on the magnitude of the surgery10,29 and whether general anesthetic is used.28,30 Postoperative pain also is contributory, as is evident from the fact that urine levels of 17-hydroxycorticosteroids remain increased during the recuperative phase (three to six days after surgery),28 and the plasma cortisol levels decline after postoperative administration of an analgesic.29 General anesthesia. General anesthesia in corticosteroid-treated patients significantly depresses the plasma cortisol response to surgery compared with that in patients who have not received corticosteroid drugs.31,32 This may be an effect of steroid-induced AI or the use of barbiturate anesthetic drugs that can lower cortisol production.30,33 Although the role of these factors has not been fully determined, several prospective studies have shown that the vast majority of patients who regularly take the daily equivalent dose of steroid or less (that is, mean dose, 5 to 10 mg of prednisone daily) for renal transplantation or rheumatoid arthritis maintain adrenal function and do not require supplementation for minor surgical procedures.31,34,35 Furthermore, for minor surgery, the risk of adrenal crisis appears to be low. A significant proportion of patients receiving prednisone therapy (5 to 50 mg daily) for between six days and 10 years who stopped therapy before surgery produced plasma cortisol levels similar to those of healthy subjects for up to seven days after minor or major surgery, and followed a normal postoperative course.29,32,34 Salem and colleagues26 suggested that clinicians replace glucocorticoids only in an amount equivalent to the normal physiological response to surgical stress, and that the risk of an adverse outcome depends on the duration and severity of the surgery, the preoperative glucocorticoid dose and the overall health of the patient. Kehlet and Binder10 and Hume and colleagues24 estimated that an average adult secretes 75 to 150 mg a day in response to major surgery, and 50 mg a day during minor procedures. Based on these findings, Salem and colleagues26 made the following general surgery and general anesthesia recommendations.

Minor surgical stress. For minor surgical stress, the glucocorticoid target is about 25 mg of hydrocortisone equivalent on the day of surgery. For example, an asthmatic patient who takes 5 mg of prednisone every other day should receive 5 mg of prednisone before surgery. Moderate surgical stress. For moderate surgical stress, the glucocorticoid target is about 50 to 75 mg per day of hydrocortisone equivalent for up to one to two days. For example, a patient with systemic lupus erythematosus who takes 10 mg of prednisone daily should receive 10 mg of prednisone (or parenteral equivalent) before surgery and 50 mg of hydrocortisone intravenously during surgery. On the first postoperative day, 20 mg of hydrocortisone is administered intravenously every eight hours (that is, 60 mg per day). The patient returns to his or her preoperative glucocorticoid dosage on postoperative day 2.

Scenario

SCENARIO:

Mrs. Santos, 50 years old, has been complaining of swollen, painful right knee joint with limited motion and experiences stiffness especially in the morning and after periods of inactivity for over 3 years now. She has been ambulating with the aid of a single tip cane and has limited activities since then. She was diagnosed to have Rheumatoid Arthritis. She tried anti-inflammatory medications as prescribed by a physician. These worked for a time but due to increasing pain, she was prescribed intra-articular corticosteroid injections. She has been maintained on oral corticosteroids for the past 2 months for control of inflammation.

Last week, she sought consultation with an orthopedic surgeon and was finally convinced to undergo arthoplasty. Her knee joint would be replaced with prosthesis. She was admitted at the Orthopedics Ward for pre-operative preparations. The operation will not be until a few days time because of her corticosteroid use. As the nurse in charge, what is your health education plan for her prior to surgery?

PLANNING:

At the end of the nurse in charge’s shift, the patient will be informed of the need to taper down corticosteroid use prior to surgery.

POINTS FOR HEALTH EDUCATION:

Dosage should be tapered when discontinuing from high doses or long term therapy to give the adrenal glands a chance to recover and produce adrenocorticoids.

Corticosteroid therapy causes immunosuppression. She would be predisposed to increased risk of infection and masking sign of infection. We don’t want our clients to be in a compromised state especially because she is undergoing surgery.

Corticosteroids may also cause hyperglycemia due to increased gluconeogenesis and impaired glucose tolerance which could contribute to poor wound healing.

Corticosteroids may cause thromboembolism. Since the patient would have to use a knee immobilizer after surgery and would be in a position with restricted blood flow, corticosteroids must be tapered before discontinuing it.

SCENARIO 2Mrs. B will be undergoing laparoscopic cholecystectomy the following day. During the interview for the patient verbalizes she is using prednisone every day for her asthma as a maintenance drug. The doctor explains the possible effects of her corticosteroid intake to surgery; Ms. B signed the informed consent for the surgery.Potential nursing diagnoses: high risk for infection: the state in which an individual is at increased risk for being invaded by pathogenic organismsSuppression of inflammation and modifications of immune response are the effects of corticosteroids. It can lower a person's resistance to infection and can make infections harder to treat. This drug causes immunosuppression and may mask symptoms of infection.Nurses responsibility and Patient teaching:•Since the patient will be undergoing surgery she should be place in a single room.“ma’am we will be admitting you in a single room, since you are taking corticosteroids which lowers your resistance and at the same time undergoing surgery. This is to avoid acquiring any infections from other patients.”•Maintain asepsis for dressing changes“dr. d, please use the clean gloves we provided in changing the dressing of the patient”•Proper hand washing before and after handling the patient. Teach patient to wash hands frequently•“Ma’am please do proper hand washing like what I demonstrated awhile ago. , especially after toileting, before meals and before and after administering self care. Because this can spread infection from one part of the body to another. Hand washing reduces this risk”•Instruct patient to limit visitors to.“ ma’am I’m sorry to inform you but we need to limit your visitors this is to reduce the number of organism your environment”•Encourage to do coughing and deep breathing exercises and to use incentive spirometer. “Mrs. B, please do coughing and deep breathing exercises at least 10 every hour, during waking times only. These measures reduce stasis of secretions in the lungs and bronchial tree.”•Administer antimicrobial drugs as ordered.

CONCLUSION Available studies suggest that prolonged

steroid use may be associated with increased bleeding or may cause serious thrombotic complications with hypercoagulability. Whether steroid administration contributes to increased perioperative bleeding, thereby causing increased transfusion requirements, remains unclear. Study therefore tested the hypothesis that preoperative steroid use increases intraoperative erythrocyte (RBC) transfusion in adults undergoing non-cardiac surgery. Secondary goals of the study were to evaluate associations between prolonged steroid and thrombotic complications, wound infection, and systemic infection.

Another steroid use outcomes were 30-day systemic infection (including sepsis and septic shock), wound infection (including superficial and deep surgical site), and thrombotic complications (identification of a new blood clot or thrombus within the venous system) within 30 days of the operation.

In summary,Analysis of a large well-validated registry indicates that long-term corticosteroid use was not independently associated with increased intraoperative transfusion requirement.

Considering all available data, we also conclude that there remains insufficient evidence to support an association between long-term steroid use and an increased risk of thromboembolic events in surgical patients.

In contrast, our results confirm previous reports that long-term corticosteroid use augments the risk of both systemic and wound infections. Clinicians might thus take precautions against infections in patients who are long-term steroid users, but the effect of long-term steroid use on coagulation-related complication—if any—seems to be of limited clinical consequence.

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