VCU DEATH AND COMPLICATIONS CONFERENCE

 Complication  Necrosis of ileostomy  Procedure  Parastomal hernia repair, revision of ileostomy  Primary Diagnosis  Crohn’s colitis, parastomal hernia

Clinical History  43yo F h/o Crohn’s colitis s/p total proctocolectomy with end ileostomy at OSH in 2002  Subsequently developed a very large parastomal hernia

Clinical History  PMH  Crohn’s colitis  Pyoderma gangrenosum  HTN  Morbid obesity  Depression  PSH:  Total proctocolectomy with end ileostomy 2002  Lap gastric band  Medications  Cellcept  Humira  Prednisone 20mg every other day  Lisinopril  HCTZ  Celexa  Allergies  PCN

Clinical History

 5/31  Repair of parastomal hernia with Proceed mesh underlay  Revision of ileostomy, relocation to left side of abdomen  POD 1-3  Hypotension, fluid resuscitation, persistently low UOP, ARF  Steroid taper started POD 3  Required CVVH and 2 episodes of intermittent HD  Improvement in UOP and creatinine returned to normal  POD 7-13  Resolving ileus, tolerating diet  Ileostomy noted to be dark, but productive

Clinical History  POD 7-13  Resolving ileus, tolerating diet  Ileostomy noted to be dark, but productive  POD 15  Pt c/o new pain at ostomy site and left flank  Ostomy noted to have lateral muco-cutaneous separation  WBC 15  POD 16  New erythema along left flank  WBC 32  Taken to OR for re-exploration, found to have perforation of ileostomy at level of the fascia, 10cm of distal ileum resected, ileostomy moved to midline, necrotic soft tissue debrided

Analysis of Complication Was the complication potentially avoidable? – Yes, hypotension could have been avoided with perioperative steroid administration to prevent adrenal insufficiency Would avoiding the complication change the outcome for the patient? – Yes, avoidance of ARF, necrosis of ostomy, reoperation What factors contributed the complication? Hypotension, lack of perioperative steroid administration, pt’s body habitus to a lesser extent

Steroids and Adrenal Insufficiency  Approximately 34 million prescriptions written for steroids every year  Fraser, et al 1952  First described a steroid-dependent pt who died of intractable hypotension postoperatively after orthopedic procedure  Since then, stress doses of steroids have become a regular part of perioperative management.  Chronic steroid use suppresses the hypothalamic-pituitary-adrenal axis  Pts unable to mount appropriate response to stress of a surgical procedure  Most severe result is hypotension and cardiovascular collapse  Recommended stress dose  100mg hydrocortisone perioperatively, followed by…  50mg hydrocortisone x 24 hours then taper dose by ½ per day until maintenance dose is reached

Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12) Review of 2 RCTs and 7 cohort studies 315 patients undergoing 389 procedures

Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12)  In 2 RCTs (37 pts)  No difference in hemodynamic profile between pts receiving stress doses of steroids compared to pts receiving only their usual daily dose  7 cohort studies (278 pts)  Pts that continued to receive usual daily dose of steroid without addition of stress dose No pts developed unexplained hypotension  Pts who had steroids stopped hours prior to surgery 2 pts developed unexplained hypotension Both responded to administration of hydrocortisone and fluids

Marik, P et al. Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Liteature. Archives of Surgery. 2008; 143(12)  Conclusion  Suggests that in pts receiving long-term corticosteroid therapy, stress doses of steroids are not required However, pts should still continue to receive their usual daily dose  Small sample size