2. Anesthetic Implications for Patients on Steroids Undergoing Surgery Claire Yang, SRNA Duke Class of 2013

3. Case Presentation

5. Steroid-induced Adrenal Insufficiency

6. Objectives Review physiology of the Hypothalamic Pituitary Axis – specifically glucocorticoid regulation during increased stress as seen in surgery Identify the patient population most susceptible to adrenocortical hypofunction. Recognition of adrenal suppression and secondary adrenal insufficiency Perioperative management of patients treated with glucocorticoids

7. Hypothalamic-Pituitary-Adrenal (HPA) Axis

10. Cortisol: Essential for Life Cortisol (synthetic form: hydrocortisone) Required for vascular and bronchial smooth muscle to be responsive to catecholamines Aids in fats, protein, and carbohydrates metabolism  Blood sugar through gluconeogenesis Anti-inflammatory

11. Cortisol Secretion Highest in the morning (20ug/dL) Lowest around midnight (5ug/dL) Normal daily output: 10-20mg/day General anesthesia and surgery: 150 mg/day

12. Activate HPA  Cortisol Surgical stress Trauma Sepsis Hypoglycemia Hypothalamic-Pituitary-Adrenal (HPA) Axis in Healthy People Stoelting’s, 5 th ed

13. Addison’s dx Normal ACTH Destruction of adrenal cortex 1° Adrenal Insufficiency  ACTH Pituitary surgery/irradiation Chronic synthetic glucocorticoid use 2° Adrenal Insufficiency

14. Biochemical Diagnosis of Adrenal Insufficiency ACTH-stimulation test Withhold exogenous steroids x24 hrs* Baseline cortisol level IV synthetic ACTH 250ug ✓ Cortisol level at 30 and 60 minutes later A cortisol level < 20 μg/dL at any time point shows adrenal insufficiency

15. Adrenal insufficiency: S/S Fatigue, weakness, anorexia Nausea and vomitting Hypotension Hypovolemia Hyponatremia Hyperkalemia Acute adrenal crisis  circulatory collapse

16. Rheumatoid arthritis COPD Exacerbation Asthma Flare Crohn’s ds Low Back Pain Common Chronic Conditions Treated with Glucocorticoids Head Trauma Recent Use of Etomidate Trauma Patient Populations Potentially at Risk for HPA axis Suppression

17. All Kinds of Formulation Oral IV Inhaler Topical ointment/creams Intra-articular injections for arthritis Epidural injections for lumbar disk pain Eye drops Nasal spray

18. Benefits Adverse Effects Osteoporosis Decreased immune response Steroids-induced diabetes Hypertension Avoid Vascular Collapse Maintain Homeostasis

19. Adverse Effects of Glucocorticoids Hypertension Glucocorticoid-induced Diabetes Decreased immune response Osteoporosis Peptic ulcer disease Fatty liver

20. Supra-physiologic Dosing > 7.5mg Prednisone per day or its equivalent Cushingoid appearance Hypothalamic-pituitary-adrenal suppression Adrenal suppression:  cortisol production When discontinued abruptly: risk for Adrenal insufficiency Cleveland Clinic J Med, 78(11), 748-756

21. Various Steroids and Equipotent Doses (Oral or IV)

22. Adrenal Suppression with Exogenous Steroids Adrenal Suppression secondary to corticosteroid therapy depends on multiple factors: Dose Duration Frequency Time Route of Administration Clinical Relevance Onset: as early as 1 week after starting corticosteroid therapy Recovery: can take from 2 weeks to 6-12 months

23. Management of Anesthesia for Patients Treated with Glucocorticoids

24. No specific anesthetic agents and/or technique are recommended in managing patients with or at risk for adrenal insufficiency

25. Who should receive steroid cover for surgery?

26. Suppressed HPA Axis Patients receiving > 20mg/day of prednisone for greater than 3 weeks Any patient on glucocorticoids with Cushing’s appearance Intermediate Patients Patients on doses of 5mg/day to 20mg/day Patients have variability in HPA axis suppression Dependent on age, sex, dose, duration of therapy Consider evaluation of HPA axis suppression by way of morning serum cortisol or ACTH stimulation tests Intra-Articular and Spinal Glucocorticoid Injections HPA axis suppression has been reported Factors include dose, interval and number of glucocorticoid injections Suggest testing of HPA axis suppression in patients receiving > 3 injections (Hamrahian, Roman, & Milan, 2012)

27. Hydrocortisone (Solu-Cortef) Supplementation Local anesthesiaNo supplement Take usual AM dose Minor (inguinal hernia repair) + 25mg IV Moderate (cholecystectomy, total joint, hysterectomy) + 50-75mg IV taper 1-2 days Major (Cardiac, liver, whipple) + 100-150mg IV taper 1-2 days Salem et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg 1994; 219: 416-25

28. Hamrahian, A., Roman, S., & Milan, S. (2012)

29. Treatment of Acute Adrenal Crisis

30. Hydrocortisone 100mg IV Hydrocortisone 10mg/hr x 24 hrs Fluid replacement (D5 NS) Glucose replacement and monitoring Arterial line placement/ABG Vasopressor and inotropic support

31. Conclusion and Further Research Adrenal hormones are essential for life. Too much or too little can be dangerous

32. Conclusion and Further Research It appears, within the literature, at the very least, patients should receive their steroid regimen leading up to surgery

33. Conclusion and Further Research Those who miss doses, should be considered at risk Administering supplemental steroids should be considered based on the type and duration of the surgery

34. Conclusion and Further Research Furthermore, the benefit of administering steroids outweighs the risk or consequences of steroid administration

35. References Axelrod, L. (2003). Perioperative management of patients treated with glucocorticoids. [Review]. Endocrinol Metab Clin North Am, 32(2), 367-383 Hamrahian, A., Roman, S., & Milan, S. (2012, August). The Surgical Patient Taking Glucocorticoids. Retrieved from www.UpToDate.com Lansang, M. C., & Hustak, L. K. (2011). Glucocorticoid-induced diabetes and adrenal suppression: how to detect and manage them. [Review]. Cleve Clin J Med, 78(11), 748-756. doi: 10.3949/ccjm.78a.10180 Pavlaki, A., Magiakou, M., Chrousos, G. (2011). Chapter 13: Adrenal insufficiency. Retrieved from www.endotext.org Salem, M., Tainsh, R. E., Jr., Bromberg, J., Loriaux, D. L., & Chernow, B. (1994). Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. [Review]. Ann Surg, 219(4), 416-425.

36. References Wakim, J. H., & Sledge, K. C. (2006). Anesthetic implications for patients receiving exogenous corticosteroids. [Review]. AANA J, 74(2), 133-139 Welsh, G., Manzull, E., Nieman, L. (2007). The surgical patients taking glucocorticoids. UpToDate. Retrieved from www.UpToDate.com