Corticosteroids

Corticosteroids

Steroids are a widely used group of drugs in anesthesia practice. When used judiciously they have proved to be of immense help. There is an increasing application of steroid therapy during perioperative period for various purposes. Some of the current indications are:

• Perioperative replacement therapy.
• Anti-inflammatory uses and hyper-reactive airway
• Post operative nausea and vomiting (PONV)
• Analgesia adjunct
• Anaphylaxis
• Septic shock
• Other indications like - cerebral edema, various surgical causes.

Steroids in Replacement Therapy

Steroid administration is necessary in perioperative period in patients treated for hypoadrenocorticism or in a patient with separation of pituitary adrenal axis owing to present or previous steroid intake. The increase in circulating cortisone levels in response to surgical trauma is one of the important components of stress response of our body. In perioperative setting this response is essential to avoid hemodynamic instability, metabolic, electrolyte, and fluid imbalances.

Stress-associated adrenal insufficiency in some patients may require additional steroids perioperatively. A normal daily adrenal output of cortisol (30 mg) is equivalent to 5 to 7.5 mg of prednisone. In patients taking 5 to 20 mg/day of prednisone or its equivalent for more than 3 weeks, the HPA may be suppressed. The hypothalamic-pituitary axis (HPA) is suppressed with more than 20 mg/day of prednisone or its equivalent when taken for more than 3 weeks. The risk of adrenal insufficiency remains for up to 1 year after the cessation of high-dose steroids. During the stress of surgery, trauma, or infection an intact HPA will respond by increasing output of glucocorticoid. Supplementation with steroids depends on the amount of stress, duration and severity of the procedure, and the regular daily dose of steroid.

Steroids as Anti-Inflammatory and Other

Steroids profoundly alter immune responses. These can prevent or suppress inflammation in response to multiple inciting events including radiation, mechanical, chemical, infectious and immunological stimuli. Steroids inhibit the production of various inflammatory factors which are critical in generating and propagating the inflammatory response.

Steroids in hyper-reactive airway: Although steroids are not true bronchodilator, they have well established usefulness in hyper-reactive airway. Their action is mainly by virtue of their anti-inflammatory action leading to decreased mucosal edema and prevention of release of bronchoconstricting substances. The most commonly encountered hyper-reactive states in anesthetic practice are patients with history of asthma, recent upper respiratory tract infection, and difficult airway, multiple intubation attempts, aspiration, foreign body bronchus and airway surgeries. In these settings, usually, steroid is given in anti-inflammatory doses to have their beneficial role of preventing inflammatory mediated airway edema as well as bronchoconstriction.

Steroids and post operative nausea and vomiting (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 anesthesia. The mechanism by which it reduces PONV is not known, but is thought to be due to decrease in production of inflammatory mediators which are known to act on the chemoreceptor trigger zone area as well as improve the blood-brain barrier function.

Steroids and anaphylactic/ allergic reaction: Steroids cannot be the mainstay of therapy in anaphylaxis because of the delayed onset of action, so they are used as adjunct after initial treatment with epinephrine (adults): 0.5ml of 1:1000 intramuscular or subcutaneous, which may be used every 15 min for up to 3 times. Glucocorticoid can supplement primary therapy to suppress manifestations of allergic diseases of a limited duration like high-fever (inflammation in the nasal passage and eyes caused by an allergic reaction), urticaria (an allergic reaction where the skin forms irritating reddish patches), contact dermatitis, drug reactions, bee stings, and angioneurotic edema (sudden accumulation of fluid under the skin). In very severe diseases intravenous methylprednisolone125mg every 6 hours, or equivalent can be used.

Steroids and sepsis/septic shock: Patients having severe sepsis or in septic shock were found to have occult or unrecognized adrenal insufficiency, incidence may be as high as 28% in seriously ill patients. Clinically it has been shown that in sepsis with adrenal insufficiency, steroid supplementation was associated with significantly higher rate of success in the withdrawal of vasopressors therapy. Usually steroids are administered in this setting to meet the steroid requirement of body, for fighting the ongoing stressful condition. The commonly used steroid is hydrocortisone 100-125mg/day.

Steroids are of value in reduction or prevention of cerebral edema. In the management of patient with brain tumor, it is common for subjects who are somnolent on admission, to respond within hours, to a loading dose of dexamethasone (8 to 32mg) and to appear alert and without neurological deficits by the following day.

Frequently report adverse effect includes gastrointestinal bleeding, super- infections, and hyperglycemia. Other potential adverse effects include sodium and water retention, hypokalemia, and reduced wound healing, although these are not typically reported. The adverse effect profile of short-term steroid therapy is limited.