Case 29 - periop steroid admin Flashcards
what are the glucocorticosteroid physiologic effects?
- produced by adrenal gland
- stimulated by ACTH (ant pituitary)
- increase blood glucose, mobilize fatty acids, catabolism, antiinflammation
what are the equivalent doses of different steroids?
Hydrocortisone - 20 mg
Prednisone - 5 mg
Methylprednisolone - 4 mg
Dexamethasone - 0.75 mg
how much is normal cortisol produced?
- normal conditions - 30 mg / day
- stressful conditions - up to 300 mg / day
What is addison’s disease?
Etiology
- lack of endogenous cortisol and aldosterone production
- hypofunctioning / nonfunctioning adrenal gland
Cause
- Iatrogenic
S/Sx:
- s/sx of no cortisol or aldosterone in body
- hypotension
- hypoglycemia
- fatigue / weakness
- increased skin pigmentation
- decrease aldosterone = low Na+ and hyperkalemia
Addison crisis = acute adrenocortical insuffiency with severe presentation of shock, coma, death).
What is Cushing syndrome?
Etiology
- excessive cortisol
Cause
- adrenal hyperplasia (primary)
- ectopic ACTH secretion (pit adenoma - secondary)
- Iatrogenic - excess cortisol admin
S/Sx:
- buffalo hump
- HTN
- hyperglycemia
- abdominal striae
- inc aldosterone = edema
- hirsuitism
What is the difference between cushing syndrome vs cushing disease?
Etiology is different between both:
Cushing Syndrome
- iatrogenic - excessive exogenous steroid admin
- non-iatrogenic - bilateral adrenal hyperplasia-> stimulates adrenal gland to produce.
- due to ectopic ACTH secretion or adrenal adenoma
Cushing Disease
- when excessive ACTH comes from pituitary (ex pituitary adenoma), then it is called cushing dz
what is a stress dose; do you need to add mineralocorticoid?
patients on long-term steroids will experience adrenalcortical insuffiency (unable to generate endogenous cortisol and mineralocorticoids)
- stress dose given to those will experience stressful surgeries.
stress dose
-
hydrocortisone equivalent to 200-300mg per day
- common dosing is hydrcortisone 100mg q8h or 50mg q6h
- minneralocorticoid activity of hydrocortisone is sufficient (therefore, no additional mineralocorticoid needs to be added (fludrocortisone) ).
how long after d/c of steroids should a patient be considered adrenally suppressed and tx accordingly?
patients on long-term steroids - may take up to a year for adrenal glands to recover after d/c steroids
author’s principles for steroid therapy:
- major surgical procedures require hydrocortisone doses of > 200mg for > 2 days
- decadron used for antiemetic properity (typically 8mg IV) is equivalent to 200mg of hydrocortisone, and this should be sufficient enough to prevent adrenal insuffiency resulting from most common surgeries.
aside from preventing adrenocortical insuffiency, what other uses do steroids provide?
- prevent PONV
- reduce swelling
- transplant anti-rejection
- asthma
- colitis
- shock
- ARDS
- cerebral edema
how is adrenal reserve evaluated
1) 24 hour urine free cortisol collection
2) ACTH stim test
- admin 250 mcg of cosyntoprin (ACTH analogue)
- measure basline cortisol level, admin cosyntropin, measure cortisol level 30 and 60 min after.
- plasma cortisol > 9 mg/dL indicates adrenal function intact
should steroids be given in patients with septic shock?
- CORTICUS trial –> no differnece in 28 day mortality for responsders and nonresponders to the ACTH stim test whether they recieved corticosteroids or placebo
- hydrocortisone group responded well to septic shock, but course c/b superinfection and new sepsis or septic shock
- admin hydrocortisone only in tx of vasopressor-resistant shock (defined as need for increasingly higher doses of vasopressors or need of second vasopressore despite adequate fluid admin)
- can consider an ACTH stim test
what is steroid therapy duration for critical illness (ex sepsis)
typically 5 to 10 days with tapering, but also depends on clinical response to therapy.
