Corticosteroids to be withheld prior to surgery?

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Corticosteroids to be withheld prior to surgery?

  1. 1. Why corticosteroids have to be withheld prior to surgery?
  2. 2. Advance Pathophysiology N 204 Group 3 <ul><li>CAMINCE, AILYN ORBETA </li></ul><ul><li>CAPITO, JAYNE PETRICIA MILLAREZ </li></ul><ul><li>CARAVEO, MARY LORELEI </li></ul><ul><li>CASILAO, SHERRY LYN MOJICA </li></ul><ul><li>CASTILLO, ANA JURY HERNANDEZ </li></ul><ul><li>CASTRO, VICTORINA MANGIBUNONG </li></ul><ul><li>CEREZO, MELANIE SAYABOC </li></ul><ul><li>CISCAR, ABIGAIL CONANAN </li></ul><ul><li>COBANGBANG, ANTHONY </li></ul><ul><li>COLENDRES, CHARMAINE ASENCIO </li></ul><ul><li>CRUZ, KATHLEEN ROSE ROSAL </li></ul><ul><li>CRUZ, KATRINA BELBIS </li></ul><ul><li>DAILEG, ANNALIZA AROLA </li></ul><ul><li>DAZA, MA. BERNADETTE CRUZ </li></ul><ul><li>DE JESUS, GAYZELL ALMIRAÑEZ </li></ul><ul><li>DE VEYRA, ANNABELLE MONTEJO </li></ul><ul><li>DELA CRUZ, SHIELISSE RAMOS </li></ul>Date Submitted : 26 June 2011 Submitted To: Professor Rita Ramos
  3. 3. How we come up with the answers
  4. 4. Pharmacology : Corticosteroid
  5. 5. Actions Important to distinguish between physiological effects (replacement therapy) and pharmacological effects (occur at higher doses) <ul><li>Mineralocorticoid </li></ul><ul><li>Na retention by renal tubule </li></ul><ul><li>increased K excretion in urine </li></ul><ul><li>Glucocorticoid </li></ul><ul><li>CHO metabolism: increased gluconeogenesis, ± peripheral glucose uptake may be decreased with resultant hyperglycaemia ± glycosuria </li></ul><ul><li>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 </li></ul><ul><li>fat deposition: increased on shoulders, face and abdomen </li></ul><ul><li>inflammatory response depressed </li></ul><ul><li>allergic response depressed </li></ul><ul><li>antibody production reduced by large doses </li></ul><ul><li>lymphoid tissue reduced (including leukaemic lymphocytes) </li></ul><ul><li>decreased eosinophils </li></ul><ul><li>renal urate excretion increased </li></ul><ul><li>euphoria or psychotic states may occur. ? due to CNS electrolyte changes </li></ul><ul><li>anti-vitamin D action </li></ul><ul><li>reduction of hypercalcaemia (chiefly where this is due to increased absorption from gut: vit D intoxication, sarcoidosis) </li></ul><ul><li>increased urinary Ca excretion. Renal stones may form </li></ul><ul><li>growth reduction where new cells are being added (eg in children) but not where they are replacing cells as in adult tissues </li></ul><ul><li>suppression of HPA axis. NB steroid suppressed adrenal continues to secrete aldosterone </li></ul>
  6. 6. <ul><li>prednisolone is standard choice for anti-inflammatory therapy. Can be given orally or IM </li></ul><ul><li>methylprednisolone used for IV pulsed therapy </li></ul><ul><li>dexamethasone longer acting. </li></ul><ul><li>fludrocortisone used to replace aldosterone where the adrenal cortex has been destroyed </li></ul><ul><li>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. </li></ul>
  7. 7. <ul><li>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. </li></ul><ul><li>In the case of perioperative complications continued glucocorticoid administration consistent with the postoperative stress response is appropriate </li></ul>
  8. 8. Individual steroids
  9. 9. Treatment of intercurrent illness
  10. 10. CONCEPTS learned
  11. 11. 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
  12. 12. Stress <ul><li>Are stimuli affecting life processes and alters a persons adaptation / development </li></ul><ul><li>Yes, Stress response acts to protect the body. Unfortunately, even for its natural, protective, adaptive characteristics; </li></ul><ul><li>There are individual differences in response to stress limit in its ability to compensate </li></ul><ul><li>There are individual differences in response to stressors </li></ul><ul><li>Increase Magnitude / Duration of stress may result to DEATH </li></ul>
  13. 14. <ul><li>CORTICOSTEROIDS </li></ul><ul><li> </li></ul><ul><li>produce synthetic hormones </li></ul><ul><li>(cortisol) </li></ul><ul><li>  </li></ul><ul><li>attack tissue decrease inflammatory </li></ul><ul><li> causing substances </li></ul><ul><li>block WBC produce by immune cells </li></ul><ul><li> </li></ul><ul><li>suppressing inflammation </li></ul><ul><li>  </li></ul><ul><li>INFLAMMATION </li></ul><ul><li>  </li></ul><ul><li>Stimulus (tissue damage/injury from surgery) </li></ul><ul><li> </li></ul><ul><li>cellular stage </li></ul><ul><li>WBC (leukocytes) adhere to vessel wall </li></ul><ul><li> </li></ul><ul><li>process emigration , leukocytes squeeze </li></ul><ul><li>through wall and move into the injured tissue </li></ul><ul><li> </li></ul><ul><li>leukocytes wander around the tissue and guided by chemical subsance called chemotaxis </li></ul><ul><li> </li></ul><ul><li>leukocytes culminates by engulfing the bacteria ( phagocytosis ) </li></ul><ul><li> </li></ul><ul><li>exudates (product of phagocytosis) which accumulates </li></ul><ul><li> </li></ul><ul><li>eventually will heal </li></ul><ul><li>  </li></ul><ul><li>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. </li></ul>
  14. 15. Related Articles
  15. 16. The surgical patient taking glucocorticoids <ul><li>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 &quot;stress dose&quot; 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 </li></ul><ul><li>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) </li></ul><ul><li>   Increased risk of fracture, infections, gastrointestinal hemorrhage, or ulcer [5,6]. (See &quot;Major side effects of systemic glucocorticoids&quot;. </li></ul>
  16. 18. <ul><li>Patients who are taking glucocorticoids should be monitored carefully for infection postoperatively, because glucocorticoids may suppress the fever response. </li></ul>
  17. 19. Perioperative Medication Management (2008) <ul><li>An article by Nafisa K. Kuwajerwala. &quot;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.” </li></ul>
  18. 20. Precautions for Patients on Steroids Undergoing Surgery <ul><li>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: </li></ul><ul><li>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. </li></ul><ul><li>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). </li></ul><ul><li>Long term and other side effects of steroid therapy . These include: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Fatty liver </li></ul></ul><ul><ul><li>Susceptibility to infection </li></ul></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Avascular necrosis of bone </li></ul></ul><ul><ul><li>Skin sepsis </li></ul></ul><ul><ul><li>Electrolyte disturbance: hypokalaemia , metabolic alkalosis </li></ul></ul><ul><li>There are pre-operative, per-operative and post-operative factors to be considered when assessing and managing these risks. </li></ul>
  19. 21. The risk of adrenal suppression <ul><li>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 </li></ul><ul><li>Pre-operative considerations. </li></ul><ul><ul><li>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). </li></ul></ul>
  20. 22. <ul><ul><li>Dosages of less than 5 mg prednisolone per day are not significant and no steroid cover is required. </li></ul></ul><ul><ul><li>10 mg/day or more of prednisolone (or equivalent) is generally taken as the threshold dose for 'steroid cover'. </li></ul></ul><ul><ul><li>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 </li></ul></ul>
  21. 23. <ul><li>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. </li></ul><ul><li>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 reduced 4 because excessive doses cause adverse effects such as post-operative infection, gastrointestinal haemorrhage and delayed wound healing. </li></ul>
  22. 24. Pre-operative assessment <ul><li>This should focus on the history of steroid usage, routine examination (including blood pressure ) and basic investigations including: </li></ul><ul><li>FBC. </li></ul><ul><li>U and Es. </li></ul><ul><li>Blood glucose </li></ul><ul><li>Liver function tests </li></ul><ul><li>Investigation for adrenal suppression is rarely done. 1 It is possible to assess this 6 with: </li></ul><ul><li>Serum and urinary cortisol </li></ul><ul><li>Short synacthen test (SST) - more popular but interpret with care. 6 </li></ul><ul><li>Insulin tolerance test </li></ul><ul><li>CRH measurement </li></ul>
  23. 25. Peri-operative management <ul><li>It is useful to summarize who should receive steroid cover for surgery (and during major illness): </li></ul><ul><li>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). </li></ul><ul><li>Patients who have received corticosteroids 10 mg daily within the three months preceding surgery. </li></ul><ul><li>Patients on high dose inhaled corticosteroids (for example beclomethasone 1.5 mg a day). </li></ul><ul><li>Patients who stopped their steroids more than 3 months ago or who are taking 5 mg or less require no steroid cover. </li></ul>
  24. 26. Peri-operative steroid cover <ul><li>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 recommendations 4 are: </li></ul><ul><li>Minor surgery - 25 mg hydrocortisone at induction of anesthesia and then resume normal medication postoperatively. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul>
  25. 27. The risk of underlying disease <ul><li>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: </li></ul><ul><li>Asthma </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Glomerulonephritis </li></ul><ul><li>Idiopathic thrombocytopenic purpura </li></ul><ul><li>Cerebral oedema </li></ul><ul><li>Malignancies and chemotherapy </li></ul><ul><li>These conditions should be fully assessed pre-operatively. </li></ul>
  26. 28. 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 surgery 10 , 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 colleagues 26 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 Binder 10 and Hume and colleagues 24 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 colleagues 26 made the following general surgery and general anesthesia recommendations.
  27. 29. 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.
  28. 30. Scenario
  29. 32. <ul><li>SCENARIO 2 </li></ul><ul><li>Mrs. 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. </li></ul><ul><li>Potential nursing diagnoses: </li></ul><ul><li>high risk for infection: the state in which an individual is at increased risk for being invaded by pathogenic organisms </li></ul><ul><li>Suppression 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. </li></ul><ul><li>Nurses responsibility and Patient teaching: </li></ul><ul><li>Since the patient will be undergoing surgery she should be place in a single room. </li></ul><ul><li>“ 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. ” </li></ul><ul><li>Maintain asepsis for dressing changes </li></ul><ul><li>“ dr. d, please use the clean gloves we provided in changing the dressing of the patient ” </li></ul><ul><li>Proper hand washing before and after handling the patient. Teach patient to wash hands frequently </li></ul><ul><li>“ 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 ” </li></ul><ul><li>Instruct patient to limit visitors to. </li></ul><ul><li>“ 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 ” </li></ul><ul><li>Encourage to do coughing and deep breathing exercises and to use incentive spirometer. </li></ul><ul><li>“ 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. ” </li></ul><ul><li>Administer antimicrobial drugs as ordered. </li></ul>
  30. 33. CONCLUSION <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>In summary, </li></ul><ul><li>Analysis of a large well-validated registry indicates that long-term corticosteroid use was not independently associated with increased intraoperative transfusion requirement. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
  31. 34. References/Links Jabbour SA ; Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-7. [abstract] Hahner S, Allolio B ; Management of adrenal insufficiency in different clinical settings. Expert Opin Pharmacother. 2005 Nov;6(14):2407-17. [abstract] LaRochelle GE Jr, LaRochelle AG, Ratner RE, et al ; Recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients with rheumatic diseases receiving low-dose prednisone. Am J Med. 1993 Sep;95(3):258-64. [abstract] Milde AS, Bottiger BW, Morcos M ; Adrenal cortex and steroids. Supplementary therapy in the perioperative phase. Anaesthesist. 2005 Jul;54(7):639-54. [abstract] Kihara A, Kasamaki S, Kamano T, et al ; Abdominal wound dehiscence in patients receiving long-term steroid treatment. J Int Med Res. 2006 Mar-Apr;34(2):223-30. [abstract] Reynolds RM, Stewart PM, Seckl JR, et al ; Assessing the HPA axis in patients with pituitary disease: a UK survey. Clin Endocrinol (Oxf). 2006 Jan;64(1):82-5. [abstract] Gibson N, Ferguson JW ; Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature. Br Dent J. 2004 Laurence DR, Bennett PN. Clinical Pharmacology, 7 th ed, 1992 Chin R, Eagerton DC, Salem M. Corticosteroids. In Chernow B (ed). The pharmacological approach to the critically ill patient, 3 rd ed, 1994  Nafisa K. Kuwajerwala  Perioperative Medication Management  (2008). Subramanian V, Saxena S, Kang JY, Pollok RC: Preoperative steroid use and risk of postoperative complications in patients with inflammatory bowel disease undergoing abdominal surgery. Am J Gastroenterol 2008; 103:2373–81   http://journals.lww.com/anesthesiology/Fulltext/2010/08000/Preoperative_Prolonged_Steroid_Use

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