1. Peri operative steroid therapy
Dr.S.Parthasarathy
MD, DA, DNB,
PhD, FICA,. (IDRA)

2. History
In 1949 , Hench and colleagues discovered that it was possible to use oral glucocorticoids for the treatment of chronic rheumatoid arthritis
1952 –RA on cortisone 8 months
hemiarthroplasty
died – postmortem report –
adrenal atrophy
1953 – similar catastrophy

3. CRH --- hypothalamus
ACTH --- pituitary
Cortisol – adrenal cortex

4. Crucial life saving role
Cortisol acts in cell cytoplasm and has a role in metabolism, homeostasis, wound healing, CVS maintenance, catecholamine production, and self-regulation via a negative feedback loop to decrease secretion of CRH and ACTH

5. Who commonly takes steroids
Rheumatoid arthritis
Bronchial asthma
Inflammatory bowel disease

6. Type of surgery
Minor
Moderate
Major

7. Preoperative evaluation
history of steroid usage,
routine examination (including blood pressure) and basic investigations including CBC , blood glucose electrolytes and LFTs..
Sodium and water retention – is there ?
Serum cortisol, urinary cortisol , CRH levels – no role almost

8. Real or virtual ??
Supraphysiogical stress dose – what they did for 50 – 60 years
Perioperative cover concept
But in a review 3 out of 57 patients who developed intra op hypotension were having adrenal insufficiency
60 years of usage without evidence ?
Do we really need ?

9. A larger retrospective study in 1981 by Knudsen et al examined 250 patients with inflammatory bowel disease taking an average 40 mg of prednisone daily.
hypotensive episodes similar

10. Jasini et al studied a group of 41 patients with rheumatoid arthritis undergoing anterior synovectomy
Less stress response but clinical ?

11. Symreng et al followed a prospective cohort of 14 patients who underwent preoperative ACTH stimulation tests.
Clinical significance ? On stress response

12. In 1994, Salem et al felt that patients receiving greater than 20 to 30 mg of prednisone per day were at a reasonable risk of HPA-axis suppression and should have biochemical testing of the HPA axis if possible.
If this was not available or there was clinical evidence of adrenal insufficiency, then perioperative steroids should be given and adjusted based on the estimated surgical stress.

13. What is normal ?
Plasma cortisol concentrations increase rapidly in response to surgical stimulation and remain elevated for a variable time following surgery.
Peak values are achieved within 4–6 h after surgery or injury and return towards 24 – 72 hours

14. Compare
Efcorlin
Wysolone
Medrol

15. Who should be supplemented ?
PREDNISONE - 5 – 50 mg/day
From 8 days onwards ??
Can be ten years also
To give supplementation

16. I have been taking steroids for three years
But stopped since one month – what to do
Possibly two to three months , usually axis recover
But think of the disease duration also

17. Salem et al

18. Inhaled steroids same as parenteral steroids
steroid therapy – as usual
Patients receiving more than 2 g/day of topical steroids or more than 0.8 mg/day of inhaled steroids on a long-term basis may have adrenal suppression and should probably receive supplementation.

19. Nicholson et al

20. Jabbour et al
Taper to 50 mg tds to 25 mg tds to 25 mg od to stop on POD 4

21. A bolus of 100 mg of hydrocortisone followed by a continuous infusion at 10 mg/hr
Also accepted

22. There is no fixed steroid replacement protocol
which is widely accepted.
The amount of steroid supplementation dose and the duration should be based on the magnitude of surgical stress as well as preoperative steroid dose and the degree of HPA suppression

23. Long term steroids and anesthesia
Etomidate may transiently decrease the synthesis and release of cortisol by the adrenal cortex.
Surgical stimulation predictably increases the release of cortisol from the adrenal cortex.
Even RA produces stress response
Hypokalemia and muscle weakness – NM blockers
Osteoporosis and position
Hypertension associated with steroids

24. Steroids and PONV
Optimum dose was found to be 10mg of dexamethasone, and same dose was found to be highly effective when given immediately before induction rather than at the end of anaesthesia.

25. Steroids and pain Powerful anti inflammatory action
Decreased mediators
Decreased pain

26. Where all peri operative steroids ?
Steroids and anaphylaxis
Steroids and cerebral edema
Steroids and spinal cord injury

27. Rheumatoid arthritis
Bronchial asthma
Inflammatory bowel disease
Surgery cures IBD – others no

28. Doubts Does infection rise ?? Extra doses really matters ?
Wound complication rises ?
Chronic therapy - matters
Neurosurgical procedures – dangers !!

29. Hyperglycemia ??
Clore and Thurby-Hay propose a weight-based dosing guideline using NPH insulin for treating glucocorticoid-induced hyperglycemia associated with tapering dosages of prednisone.
This guideline suggests using 0.4 units/kg of NPH for prednisone doses ≥ 40 mg/day, with the NPH insulin dose being decreased by 0.1 unit/kg for each 10 mg/day decrease in prednisone dose
My experience 20 % rise in insulin dosage in patients receiving short term steroids

30. What s the benefit in major surgeries
Pulmonary morbidity is less if we supplement with steroids

31. Kids
Perioperative steroids effectively lower the risk of postoperative airway distress and postoperative fever in children undergoing the primary repair of their cleft palate.
This finding favors a customary role for perioperative steroid therapy in pediatric primary palatoplasty.

32. Summary
History
Indications
Dosage schedule
Benefits
Side effects