November FY20

[Kristen Horsman]

2.) Based on this article, please describe if you will make any changes to your practice, and if yes, what those changes will be.

[kristenhorsman]

The November article is presented by Ben Waldbaum. He chose an article that discusses the use of stress-dose steroids in the perioperative period for patients on chronic steroids.

The link to the article is: anesthesiology.pubs.asahq.org/article.aspx?articleid=2626031

The questions to be answered are:

1.) What is your current practice regarding administration of perioperative stress steroids for patients who are on chronic steroids? Do you differentiate between the type of surgery, their current dose, duration of therapy, and secondary adrenal insufficiency?


2.) Based on this article, please describe if you will make any changes to your practice, and if yes, what those changes will be.

[Anne McNulty CRNA]

I found this article interesting and useful. I have never had a patient with hypotension attributed to adrenal insufficiency. Attention to the daily dose and length of time on steroids is key. I have most likely overtreated patients in the past. the wound healing issue was not mentioned in this article. Steroids are wonderful drugs when used correctly.

[LarSharVeA Bailey]

I usually administer a stress dose of solucortef if the patient is on 10mg of steroids greater than four weeks AND the surgery is moderately major and beyond. Here, in the past, the entire team has discussed the length and severity of surgery and collaborated on whether a stress dose is necessary. Some surgerons are staunchly against it saying that patients typically receive too much, whereas others have deferred to our clinical judgment.

I have not experienced hypotension attributed to adrenal insufficiency, however, I have heard another provider's recount of how refractory the blood pressure is once it does occur. After reading the article, I do think it is important to take into consideration whether or not the patient took the dose the day of surgery. It may be reasonable to hold additional steroids.

[Jessica Swtizman]

Thank you for this interesting article. Steroids are wonderful drugs when used correctly and I will continue to administer stress dose steroids when appropriate for the patient.

[Ben Waldbaum]

1.)I usually administer perioperative steroids, especially for major surgery. I have yet to see a patient arrive in preop with a workup to determine if they are adrenally insufficient and there is no way for me to determine this definitively on the day of surgery.


2.) What I find most interesting in this article is that it is 2019, and a common problem such as this has no level A or level B evidence to guide care. I find it hard to argue for change with such a lack of evidence. When I think of the pro/cons, it is worth mentioning a quote from the article that in: "2016 Endocrine Society Clinical Practice Guideline6 on primary adrenal insufficiency notes that harm has not been shown from recommended doses of perioperative stress-dose steroids and thus places a higher value on preventing adrenal crisis rather than reducing the potential adverse effects of short-term overtreatment" So in the grand scheme, I'm hesitant to change practice when the downside when not administered can be so catastrophic and the harm when administered is minimal.

[Dahlia Rouchon]

1. My current practice is to administer hydrocortisone 50mg for a patient on chronic steroids for a moderate level surgery, i.e. typical Weinberg airway, or prolonged breast reconstruction case where GETA is used. I will administer 100mg hydrocortisone for more invasive surgeries, ie. ex laps for complicated hernias, bowel procedures, cancer debulking. So in this case I do differentiate. If the patient took their own prednisone, i.e. 5mg I would not dose intraoperative steroid but see how hypotension plays out and if refractory to IA adjustments, fluid resuscitation, and nonresponsive to vasopressors. I have not had to redose after the initial dose.
2. This is a good review article and I do not plan to change my practice as I have seen severe hypotension due to insufficient steroid therapy for a patient on chronic steroids after above adjustments have been made to be unsuccessful. Immediately in those cases, when the steroid was given normotension was re-established.

[Jessica Hadley]

1. Thank you for this review of perioperative steroid administration. In the past, I have favored giving stress dose steroids to patients with chronic steroids. Most times I have given between 50-100mg of Hydrocortisone. I liked how this article broke down the recommendations based on steroid dosage and type of procedure. Overall, I think I will be more aware going forward to consider the amount of steroids a patient is on and how stressful the surgery is going to be.

[Katya]

Thank you for good review article of steroid administration. I don't think I will change my practice based on this article. I usually ask patient how large the dose of steroid they take, was it reduced recently, when the last dose was taken. If they took their usual preoperative dose, I treat with rescue dose steroids only if refractory hypotension presents in the perioperative period. I give stress dose if patient on long term and large dose steroids, I give them stress dose. I give dexamethasone frequently for nausea in the beginning of case and if I don't notice untreatable hypotension during the case, I don't give additional dose of different steroid. But I agree with Ben above.

[kels]

I will probably not make any changes to my practice after this article . Like many folks I take into consideration the type of surgery ( minor , mod, major surgery ) and the timing and dosage of the p's prescribed steroids. At times I work with attendings who will say " if we have any problems with hypotension let us then give a stress dose " I prefer to not have to deal with hypotension secondary to steroids that probably should have been given in the first place/ have minimal complications if too much was given so I tend to push back on this .

[Soo-Ok Kim]

1. I normally make sure pts take their routine dose of steroid the morning of the procedure and stratify the stress level based on their current presentation and level of surgical procedure.
For minor procedure, no additional dose of steroid to be given, but for major procedure, stress dose of steroid (hydrocortisone 50-100mg) will be given. As the article mentioned, perioperative adrenal crisis with hypotension should be a diagnosis of exclusion.


2. It is a great review article for the perioperative steroid therapy, presenting there is NO strong evidence of the therapy or guidance what exactly needs to be done. Since there is little evidence to show harm to stress dose steroid approach, as Ben mentioned, I would not change my current practice.

[Wai-Ling Lo]

My practice is similar to Soo-Ok. I won't give the stress dose for minor procedures if pts are on low dose prednisone and they take the meds in the morning. For major procedures, I will give hydrocortisone 50-100mg.
I too won't change my practice for the reason mentioned by Ben.

[Jocelyn Datud]

The lack of evidence makes it controversial as to whether the administration of perioperative stress-dose steroids is the standard of care, hence, I would still stick with my practice- assessing the dose and duration of steroid, type of surgery, risk of HPAA suppression, and hypotension episodes. Based on these factors, I would determine if the patient needs a stress dose or not.

[clawry]

My current practice is to administer stress dose steroids for intermediate to major surgical procedures. I typically give 100 mg of hydrocortisone IV for stress dose steroids. This is something that I will typically have a conversation with the anesthesiologist and surgeon about prior to induction. If a patient had not taken their dose of steoid that morning, I would also give them stress dose steroids. I have never seen adrenal insufficiency intraoperatively, but realize that it is a major concern for refractory hypotension. 

Changes that I would make based upon this article would be to really examine the need for additional steroids intraoperatively. Also, I would differentiate the need for steroids based upon high risk patients for HPAA supression and low risk for HPAA suppression. 

This was an excellent review of the HPA axis and the need for additional steroids intraoperatively. 

[rboynton]

Interesting article. Years ago, we gave everyone a stress dose of steroids during major surgery. The last few years, it seems to have gone out of vogue. I do give stress dose of steroids if the pt has been on chronic steroids and its a major surgery with discussion with surgeon. Very good review.