Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Impact of glucocorticoid supplementation on reducing perioperative complications in patients on long-term glucocorticoid medication: A propensity score analysis using a nationwide inpatient database

BACKGROUND

Perioperative glucocorticoid supplementation has been suggested as a potentially effective precaution against perioperative adrenal crisis in patients on long-term glucocorticoid medication.

METHODS

This retrospective cohort study used a national inpatient database in Japan. We included patients who underwent general surgery and those who received long-term glucocorticoid medication before surgery. A one-to-one propensity score-matched analysis was performed to compare patients who received 100 mg hydrocortisone during surgery with those who received no supplementation. The primary outcome was use of vasopressor agents on the day of surgery. The secondary outcomes included bleeding, perioperative infection, wound dehiscence, postoperative length of stay, and in-hospital mortality.

RESULTS

Among the 807 propensity score-matched pairs, there was no significant difference in use of vasopressor agents between patients with and without glucocorticoid supplementation (24.5% vs. 21.9%; P = 0.22) and no significant differences in any secondary outcomes.

CONCLUSIONS

Perioperative glucocorticoid supplementation was not associated with decreased morbidity or mortality.

Postoperative Steroid Taper Is Associated With Pelvic Sepsis After Ileal Pouch-anal Anastomosis

OBJECTIVE

We hypothesized that postoperative oral steroid taper after ileal pouch-anal anastomosis for inflammatory bowel disease would not be associated with pelvic septic complications.

BACKGROUND

Recent data has emphasized the possible association between biologic medication use and pelvic sepsis following ileal pouch-anal anastomosis. Limited contemporary data exist examining the effects of steroid use on these complications.

METHODS

Consecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease at a single institution from January 2009 to December 2013 were included. Factors associated with anastomotic leak and pelvic sepsis were assessed using univariate and multivariate analysis.

RESULTS

A total of 686 patients were included (mean age 39.5 years, 59% males). Postoperative oral steroid taper was associated with both anastomotic leak and pelvic sepsis on univariate analysis. Stress dose intravenous steroid use was not associated with complications. Multivariate analysis indicated total proctocolectomy (odds ratio [OR] 2.2; confidence interval [CI] 1.01-4.7, P = 0.047), and postoperative oral steroid taper (OR 2.3; CI 1.06-5.1; P = 0.035) as independent factors significantly associated with pelvic sepsis.

CONCLUSIONS

Prolonged postoperative oral steroid taper after ileal pouch-anal anastomosis should be avoided. If preoperative steroid weaning is not possible before a planned total proctocolectomy and ileal pouch-anal anastomosis, patients should undergo an initial total abdominal colectomy.

Perioperative corticosteroid administration: a systematic review and descriptive analysis

Background

Perioperative administration of corticosteroid is common and variable. Guidelines for perioperative corticosteroid administration before non-cardiac non-transplant surgery in patients with current or previous corticosteroid use to reduce the risk of adrenal insufficiency are lacking. Perioperative use of corticosteroid may be associated with serious adverse events, namely hyperglycemia, infection, and poor wound healing.

Objective

To determine whether perioperative administration of corticosteroids, compared to placebo or no intervention, reduces the incidence of adrenal insufficiency in adult patients undergoing non-cardiac surgery who were or are exposed to corticosteroids.

Methods

We searched MEDLINE via Ovid and PubMed, EMBASE via Ovid, and the Cochrane Central Register of Controlled Trials, all from 1995 to January 2017.

Selection criteria

We included randomized controlled trials (RCTs), cohort studies, case-studies, and systematic reviews involving adults undergoing non-cardiac non-transplant surgery and reporting the incidence of postoperative adrenal insufficiency.

Data collection and analysis

Two authors independently assessed studies' quality and extracted data. A descriptive and bias assessment analysis was performed.

Results

Two RCTs (total of 37 patients), five cohort studies (total of 462 patients), and four systematic reviews were included. Neither RCT showed a significant difference in the outcome. This result was like that of the five cohort studies. The quality of the evidence was low.

Conclusion

The current use of perioperative corticosteroid supplementation to prevent adrenal insufficiency is not supported by evidence. Given the significant studies' limitations, it is not possible to conclude that perioperative administration of corticosteroids, compared to placebo, reduces the incidence of adrenal insufficiency.

Perioperative Steroid Management

Perioperative stress-dose steroid administration remains a controversial topic, with recent studies questioning its necessity. We discuss the current literature, largely published in nonanesthesiology journals, and suggest a practical approach to perioperative steroid management.

Patient optimization for surgery relating to Crohn's disease

The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.

Review article: optimal preparation for surgery in Crohn's disease

BACKGROUND

One-third of Crohn's disease (CD) patients will undergo abdominal surgery within the first 5 years of diagnosis.

AIM

To review the available evidence on pre-operative optimisation of CD patients.

METHODS

The literature regarding psychological support, radiological imaging, abdominal abscess management, nutritional support, thromboembolic prophylaxis and immunosuppression in the perioperative setting was reviewed.

RESULTS

For diagnosis of fistulas, abscesses and stenosis, ultrasonography (US), computed tomography (CT) and magnetic resonance imaging (MRI) have a high diagnostic accuracy. Under either CT or US guidance, it is possible to perform abscess percutaneous drainage (PD), which, with systemic antibiotic therapy, should be the first-line approach to intra-abdominal abscesses. CD patients with weight loss <10% within the last 3-6 months, body mass index < 18.5 kg/m(2) and/or albumin levels <30 g/L, are at an increased risk of post-operative complications. Pre-operative nutritional support should be used in these patients. IBD patients undergoing surgery have a higher risk of venous thromboembolic disease than patients with colorectal cancer, and current guidelines recommend that they should receive prophylaxis with heparin. Whether the use of anti-TNF agents before surgery increases the likelihood of post-operative complications, is the subject of much debate. To date, cumulative evidence from most studies (all retrospective) suggests that there is no such risk increment. Prospective studies are necessary to firmly establish this conclusion.

CONCLUSIONS

Preparation for surgery requires close interaction between surgeons, gastroenterologist, radiologists, psychologists and the patient. Correct pre-operative planning of surgical treatment has a major impact on the outcome of such treatment.