Steroids and Anesthetic Considerations
Steroids and Anesthetic Considerations
Steroids and Anesthetic Considerations
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<strong>Steroids</strong> <strong>and</strong><strong>Anesthetic</strong><strong>Considerations</strong>Sass 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 <strong>and</strong> monitoring Arterial line placement Vasopressor <strong>and</strong> 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 <strong>and</strong> immuneresponse Enhanced analgesia3/2/2012 26
<strong>Steroids</strong> <strong>and</strong> 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
<strong>Steroids</strong> <strong>and</strong> 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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<strong>Steroids</strong> to Reduce Postoperative PainDe Oliveira, 2011 Decadron 0.1 mg/kg is effective inreducing postoperative pain <strong>and</strong>decreasing opioid consumption afterambulatory gynecologic surgery.3/2/2012 32
<strong>Steroids</strong> <strong>and</strong> 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
<strong>Steroids</strong> <strong>and</strong> DiabetesWang Y, 2009 Physiologic stress response <strong>Steroids</strong> 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 <strong>and</strong> 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. <strong>Steroids</strong>. 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. <strong>Anesthetic</strong> 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 nausea<strong>and</strong> vomiting. Anes & Analg, 91, 139-139.Fujii, Y. & Itakura, M. 2010. Reduction of postoperative nausea,vomiting, <strong>and</strong> analgesic requirement with dexamethasone for patientsundergoing laparoscopic cholecystectomy. Surgical Endoscopy, 24,692-696.3/2/2012 36
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