PERI OPERATIVE STEROIDAL THERAPY

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PERIOPERATIVE STEROIDS : 

PERIOPERATIVE STEROIDS

Physiology of cortisol secretion : 

Physiology of cortisol secretion

ADRENAL GLANDS : 

GLUCOCORTICOIDS Control the blood sugar levels by burning fat and proteins, in response to stress or injury. MINARALOCORTICOIDS These control blood volume, regulate blood pressure. They regulate R-A-A system , control release of angiotension II. They regulate Na++ , K+ excretion. ADRENAL GLANDS

STEROIDS USES : 

Perioperative replacement therapy. Anti-inflammatory uses and hyper-reactive airway. Post-operative nausea and vomiting(PONV). Analgesia adjunct. Day care surgery. Anaphylaxis. Septic shock. Others- cerebral edema, spinal cord injury ,various surgical causes. STEROIDS USES

Slide 7: 

Long term steroid therapy for chronic diseases like asthma suppresses the hypothalamic-pituitary-adrenal (HPA) axis. Studies have shown that in normal patients with major stresses like trauma or surgery the HPA axis is activated, leading to a surge in systemic cortisol. This surge continues for up to 72 hours after the insult and is thought to be protective as cortisol has a number of anti-inflammatory effects and prevents hypotension and shock. Loss of this surge may precipitate intraoperative or postoperative haemodynamic instability.

Cortisol secretion adults _ 75-150mg of cortisol in response to major surgery and 50mg a day for minor surgery,

WHO NEEDS REPLACEMENT THERAPY : 

long term steroids equivalent to more than 10mg prednisolone daily (or who have received such a dose within the last 3 months) receive a physiological replacement regimen. WHO NEEDS REPLACEMENT THERAPY

Equivalent drug doses (British National Formulary, March 2003) : 

Equivalent drug doses (British National Formulary, March 2003)

PATIENTS WHOSE HAVE RECEIVED A REGULAR DAILY DOSE OF MORE THAN 10MG PREDNISOLONE OR EQUIVALENT IN THE LAST THREE MONTHS : 

PATIENTS WHOSE HAVE RECEIVED A REGULAR DAILY DOSE OF MORE THAN 10MG PREDNISOLONE OR EQUIVALENT IN THE LAST THREE MONTHS

ANTI-INFLAMMATORY USES : 

These can prevent or suppress inflammation radiation, mechanical, chemical, infectious and immunological stimuli. Supress both humoral and cell mediated immunity. ANTI-INFLAMMATORY USES

HYPER-REACTIVE AIRWAY : 

By virtue of their anti-inflammatory action. Decreased mucosal edema. prevention of release of bronco-constricting substances. Hyper-reactive states in anaesthetic practice are patients with history of asthma, recent upper respiratory tract infection, difficult airway, multiple intubation attempts, aspiration, foreign body bronchus, airway surgeries and COPD. HYPER-REACTIVE AIRWAY

STEROIDS AND PONV : 

Is thought to be due to decrease in production of inflammatory mediators which are known to act on the CTZ area as well as improve the blood-brain barrier function. They act synergistically 5 HT3 antagonists. 10mg of DEXAMETHASONE at the time of induction. STEROIDS AND PONV

STEROIDS AND ANALGESIA : 

Various routes of administration of steroids include parentral, local infiltration at operated site, as an adjuvant in nerve blocks and central-neuraxial blockade. The commonly used steroid is hydrocortisone 100-125mg day. Mode of analgesia-Anti inflammatory action, major role in decreasing amplifying and maintenance of pain perception. STEROIDS AND ANALGESIA

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 vasopressin therapy. STEROIDS AND SEPSIS/SEPTIC SHOCK

Steroids and day care surgery : 

DECREASE THE INCIDENCE of PONV, Postoperative pain, establish early oral intake, Produce euphoric effect by decreasing level of prostaglandins, Elevating those of endorphins Steroids and day care surgery

OTHER PURPOSES : 

1. Cerebral oedema: 2. Spinal cord injury: OTHER PURPOSES

ADVERSE EFFECTS OF STEROIDAL THERAPY : 

Hyperglycemia. Immunosuppression Protein catabolism Impaired wound healing Hypertension Fluid overload Psychosis Aseptic necrosis of femoral head. ADVERSE EFFECTS OF STEROIDAL THERAPY

Bibilography : 

Guidelinesfor perioperative steroids By Dr N Loh, Senior House Officer, and Dr M Atherton, Consultant, Department of Anaesthesia, Arrowe Park Hospital, Wirral CH49 5PE. Steroid Therapy – Current Indications in Practice V. K. Grover1, Ramesh Babu2, S. P. S. Bedi3, Indian Journal of Anaesthesia 2007; 51 (5) : 389-393 Bibilography

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