Steroids and Anesthetic Considerations

Steroids and Anesthetic Considerations

Steroids andAnestheticConsiderationsSass Elisha, CRNA, Ed.DKaiser Permanente School of AnesthesiaCANA, 20123/2/2012 1

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What is the mechanism bywhich chronic steroidtherapy may put a patientat risk of developing acuteadrenal crises?3/2/2012 3

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Drug Antinflammatory N A retaining DurationCortisol 1 1 8-12 SPrednisone 4 0.8 18-36 IDexamethasone 25 0 36-54 L3/2/2012 12

If you ran out of hydrocortisone,could you use another steroid tofor a preoperative prep?3/2/2012 14

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Do patients taking steroids viainhalation or skin routes needpreoperative steroids? Do patients who have received epiduralsteroids need a steroid prep?3/2/2012 17

Electrolyte AbnormalitiesAcute Adrenal C risesAcute Adrenal Crises Hyperkalemia Hyponatremia Hypovolemia Metabolic acidosis3/2/2012 18

What is the most common sign ofacute adrenal crises intraoperativelyduring general anesthesia? Should every patient receiveHydrocortisone 100 mg as a steroidprep?3/2/2012 19

T reatment of Acute Adrenal C rises Hydrocortisone 100 mg IV Hydrocortisone 200 mg IV infusion 24 h Fluid replacement Glucose replacement and monitoring Arterial line placement Vasopressor and inotropic support3/2/2012 20

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Etomidate-Inhibition of Cortisol3/2/2012 24

M O C-Etomidate Soft analogue of Etomidate Rapid metabolism No adrenocortical suppression3/2/2012 25

PH YSI O L O G I C E F F E C TS O FG L U C O C O R T I C O IDS Increased cardiac output/vascularreactivity Increased gluconeogenesis Decreased inflammatory and immuneresponse Enhanced analgesia3/2/2012 26

Steroids and Drug Interactions Digoxin Barbiturates/phenytoin Diuretics NSAIDS Oral anticoagulants Antidiabetic agents3/2/2012 27

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Got ST E R O IDS for PO N V? Decadron most efficacious if givenduring induction of anesthesia Decadron most effective with 8 mg dose Onset 1 h Peak 8-10 h Duration 72 h3/2/2012 29

Steroids and Septic Shock Sepsis=iNOS Increased nitric oxide=vasodilator Cytokines decrease #’s/affinity ofglucocorticoid receptors for cortisol Surviving sepsis campaign (SSC), 2002 SSC=300 mg hydrocortisone ifvasopressor dependent3/2/2012 30

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Steroids to Reduce Postoperative PainDe Oliveira, 2011 Decadron 0.1 mg/kg is effective inreducing postoperative pain anddecreasing opioid consumption afterambulatory gynecologic surgery.3/2/2012 32

Steroids and Interscalene Nerve BlocksCummings K C, 2011 Grp A-Ropivicane/Bupivicaine 0.5% Grp B-Medication above w 8 mg Decadron Decadron increased time of analgesia fromA=11-15 hrs analgesiaB=20-23 hrs analgesia3/2/2012 33

Steroids and DiabetesWang Y, 2009 Physiologic stress response Steroids increase gluconeogenesis Decadron 10 mg IV significantly increasesblood sugar 180 minutes post injection inhealthy volunteers Effects greatest in insulin dependent diabetics Should we give steroids for PONV to patientswith diabetes?3/2/2012 34

R E F E R E N C ESCotton, B. A., 2008. Increased risk of adrenal insufficiency followingetomidate exposure in critically injured patients, Arch Surg. 143(1) 62-67.Cummings KC., 2011. Effect of dexamethasone on the duration ofinterscalene nerve blocks with ropivicaine or bupivicaine,107(3),446-453.De Oliveira, GS., 2011. Dose ranging study of the effect of preoperativedexamethasone on postoperative quality of recovery and opioidconsumption after gynecologic surgery, BJA, 3, 362-371.Grover, V. K. 2007. Steroid therapy-Current indications in practice, IndianJournal of Anesthesia. 51(5), 389-393.Marik PE, Varon J. 2008. Requirement of postoperative stress doses ofcorticosteroids. Arch Surg. 143(12), 1222-1226.Elisha S, Gabot M, Giron S. 2011. Steroids. In Pharmacology for NurseAnesthesiology, Ouelette R, Joyce J, eds. 303-311.3/2/2012 35

M O R E R E F E R E N C ESVinclair, M., 2007. Duration of adrenal inhibition following a singlebolus dose of etomidate in critically ill patients, Intensive Care Med. 37-43.Wakim, J., 2006. Anesthetic implications for patients receivingexogenous corticosteroids. AANA Journal, 74(2), 133-139.Wang Y., 2009. Effects of different glucocorticoids on blood sugarduring surgery under general anesthesia. Zhonghua, 89(27),1913-15.Wang, J.J., 2000. The effect of timing of dexamethasone administrationon its efficacy as a prophylactic antiemetic for postoperative nauseaand vomiting. Anes & Analg, 91, 139-139.Fujii, Y. & Itakura, M. 2010. Reduction of postoperative nausea,vomiting, and analgesic requirement with dexamethasone for patientsundergoing laparoscopic cholecystectomy. Surgical Endoscopy, 24,692-696.3/2/2012 36

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