Supplemental perioperative steroids for surgical patients with adrenal insufficiency

Post-Acute COVID-19 Syndrome for Anesthesiologists: A Narrative Review and a Pragmatic Approach to Clinical Care

Post-acute coronavirus disease 2019 (COVID-19) syndrome is a novel, poorly understood clinical entity with life-impacting ramifications. Patients with this syndrome, also known as "COVID-19 long-haulers," often present with nonspecific ailments involving more than one body system. The most common complaints include dyspnea, fatigue, brain fog, and chest pain. There currently is no single agreed-upon definition for post-acute COVID-19 syndrome, but most agree that criterion for this syndrome is the persistence of mental and physical health consequences after initial infection. Given the millions of acute infections in the United States over the course of the pandemic, perioperative providers will encounter these patients in clinical practice in growing numbers. Symptoms of the COVID-19 long-haulers should not be minimized, as these patients are at higher risk for postoperative respiratory complications and perioperative mortality for up to seven weeks after initial illness. Instead, a cautious multidisciplinary preoperative evaluation should be performed. Perioperative care should be viewed through the prism of best practices already in use, such as avoidance of benzodiazepines in patients with cognitive impairment and use of lung-protective ventilation. Recommendations especially relevant to the COVID-19 long-haulers include assessment of critical care myopathies and neuropathies to determine suitable neuromuscular blocking agents and reversal, preoperative workup of insidious cardiac or pulmonary pathologies in previously healthy patients, and, thorough medication review, particularly of anticoagulation regimens and chronic steroid use. In this article, the authors define the syndrome, synthesize the available scientific evidence, and make pragmatic suggestions regarding the perioperative clinical care of COVID-19 long-haulers.

Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines

Immunocompromised patients are a heterogeneous and diffuse category frequently presenting to the emergency department with acute surgical diseases. Diagnosis and treatment in immunocompromised patients are often complex and must be multidisciplinary. Misdiagnosis of an acute surgical disease may be followed by increased morbidity and mortality. Delayed diagnosis and treatment of surgical disease occur; these patients may seek medical assistance late because their symptoms are often ambiguous. Also, they develop unique surgical problems that do not affect the general population. Management of this population must be multidisciplinary.This paper presents the World Society of Emergency Surgery (WSES), Surgical Infection Society Europe (SIS-E), World Surgical Infection Society (WSIS), American Association for the Surgery of Trauma (AAST), and Global Alliance for Infection in Surgery (GAIS) joined guidelines about the management of acute abdomen in immunocompromised patients.

Description of a Novel Mechanism Possibly Explaining the Antiproliferative Properties of Glucocorticoids in Duchenne Muscular Dystrophy Fibroblasts Based on Glucocorticoid Receptor GR and NFAT5

Glucocorticoids are drugs of choice in Duchenne muscular dystrophy (DMD), prolonging patients’ ambulation. Their mode of action at the protein level is not completely understood. In DMD, muscle tissue is replaced by fibrotic tissue produced by fibroblasts, reducing mobility. Nuclear factor of activated T-cells 5 (NFAT5) is involved in fibroblast proliferation. By treating one DMD fibroblast cell culture and one of unaffected skeletal muscle fibroblasts with methylprednisolone (MP) or hydrocortisone (HC) for 24 h or 12 d, the antiproliferative properties of glucocorticoids could be unraveled. NFAT5 localization and expression was explored by immunocytochemistry (ICC), Western blotting (WB) and RT-qPCR. NFAT5 and glucocorticoid receptor (GR) colocalization was measured by ImageJ. GR siRNA was used, evaluating GR’s influence on NFAT5 expression during MP and HC treatment. Cell proliferation was monitored by IncuCyte ZOOM. In DMD fibroblasts, treatment with MP for 24 h induced dots (ICC) positive for NFAT5 and colocalizing with GR. After 12 d of MP or HC in DMD fibroblasts, NFAT5 expression was decreased (RT-qPCR and WB) and growth arrest was observed (Incucyte ZOOM), whereas NFAT5 expression and cell growth remained unchanged in unaffected skeletal muscle fibroblasts. This study may help understand the antiproliferative properties of glucocorticoids in DMD fibroblasts.

Anesthetic Induction With Etomidate in Cardiac Surgical Patients: A PRISMA-Compliant Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aimed to systematically review the effects of etomidate (ETM) during anesthetic induction on patients undergoing cardiac surgery.

DESIGN

Systematic review and meta-analysis.

SETTING

Operating room.

PARTICIPANTS

Patients undergoing cardiac surgery.

INTERVENTIONS

ETM or control drugs.

MEASUREMENTS AND MAIN RESULTS

PubMed, Cochrane Library, OVID, and EMBASE were searched through August 31, 2020. Primary outcomes included hemodynamic profiles and stress responses. Secondary outcomes included morbidity, mortality, and postoperative recovery. For continuous/dichotomous variables, treatment effects were calculated as weighted mean difference (WMD)/odds ratio (OR) and 95% confidence interval (CI). A database search yielded 18 randomized controlled trials including 1,241 patients. The present meta-analysis demonstrated that ETM-anesthetized patients had lower heart rates (WMD, -3.31; 95% CI -5.43 to -1.19; p = 0.002), higher blood pressures (systolic blood pressure: WMD, 12.02; 95% CI 6.24 to 17.80; p < 0.0001; diastolic blood pressure: WMD, 5.23; 95% CI 2.39 to 8.08; p = 0.0003; mean arterial pressure (MAP): WMD, 8.64; 95% CI 5.85 to 11.43; p < 0.00001), less requirement for vasopressor (OR, 0.26; 95% CI 0.15 to 0.44; p < 0.00001), and more nitroglycerin usage (OR, 14.89; 95% CI 4.92 to 45.08; p < 0.00001) during anesthetic induction. Current meta-analysis also demonstrated that single-dose ETM lowered cortisol levels transiently and did not have a significant effect on endogenous norepinephrine and epinephrine levels and was not associated with increased postoperative inotrope and/or vasopressor requirement. Additionally, the meta-analysis suggested that ETM anesthesia was associated with neither increased mortality nor morbidity, except a higher incidence of transient adrenal insufficiency in ETM recipients.

CONCLUSION

The present meta-analysis suggested that single-dose ETM during anesthetic induction could be associated with more stable hemodynamics, transient and reversible lower cortisol levels, and a higher adrenal insufficiency incidence, but not worse outcomes in cardiac surgical patients.

Effects of Chronic Corticosteroid and Immunosuppressant Use in Patients Undergoing Bariatric Surgery

BACKGROUND

Chronic immunosuppression can put surgical patients at additional risk for complications, particularly infection. This is not a contraindication for patients undergoing bariatric surgery. However, with the increasing prevalence of bariatric surgery, it is important to characterize the additional risks for immunosuppressed patients.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry was used to identify immunosuppressed patients who had undergone bariatric surgery. Patients undergoing primary bariatric surgery (laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy) at an accredited institution between 2015 and 2017 were included. A multivariable regression analysis was performed, controlling for age, sex, procedure, and several other comorbidities. Overall 30-day incidence of major complications was the primary outcome. A secondary analysis compared outcomes amongst immunosuppressed patients by procedure type using a propensity-matched analysis. Propensity matching was performed based on preoperative comorbidities and bariatric procedure.

RESULTS

A total of 430,936 patients were included in the study. Of these, 7214 (1.7%) were chronically immunosuppressed. Our multivariable regression analysis found statistically higher odds of 30-day major complications (OR 1.39, 95% CI 1.25-1.55; p < 0.001), bleed (OR 1.49, 95% CI 1.24-1.80; p < 0.001) and anastomotic leak (OR 1.38, 95% CI 1.02-1.87; p = 0.037) amongst immunosuppressed patients. However, there was no difference between 30-day mortality (OR 1.15, 95% CI 0.64-2.07; p = 0.644). Our secondary analysis found higher rates of 30-day major complications for immunosuppressed patients undergoing gastric bypass (9.6% vs. 5.0%; p < 0.001).

CONCLUSION

Immunosuppressed patients are at higher risk of major complications when undergoing bariatric surgery, especially gastric bypass.

Management of Adrenal Insufficiency Risk After Long-term Systemic Glucocorticoid Therapy in Duchenne Muscular Dystrophy: Clinical Practice Recommendations

Long-term glucocorticoid therapy has improved outcomes in patients with Duchenne muscular dystrophy. However, the recommended glucocorticoid dosage suppresses the hypothalamic-pituitary-adrenal axis, leading to adrenal insufficiency that may develop during severe illness, trauma or surgery, and after discontinuation of glucocorticoid therapy. The purpose of this review is to highlight the risk of adrenal insufficiency in this patient population, and provide practical recommendations for management of adrenal insufficiency, glucocorticoid withdrawal, and adrenal function testing. Strategies to increase awareness among patients, families, and health care providers are also discussed.

Perioperative "stress dose" of corticosteroid: Pharmacological and clinical perspective

Various exogenous steroid preparations have been in use for a wide range of indications. We, as an anesthesiologist often encounters a surgical patient receiving chronic steroid therapy. Perioperative use of steroid is associated with major complications such as full-blown adrenal crisis in the perioperative period due to the secondary adrenal insufficiency. Henceforth, comes the role of the perioperative “stress-dose” of steroids to mitigate this rare but potentially fatal complication. There have been opposing views regarding the need and the appropriate dosage of the perioperative steroids. The present review discusses the changing concept of perioperative “stress dose” of corticosteroids, its pharmacokinetics, clinical relevance, and the related controversies such as the need and the appropriate dose.

Perioperative care of congenital adrenal hyperplasia - a disparity of physician practices in Canada

Background

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most common cause of primary adrenal insufficiency in children. Current guidelines recommend the use of perioperative stress dose (supraphysiologic) glucocorticoids for children with CAH undergoing anesthesia, although a perceived difference in practice patterns among Canadian pediatric subspecialists prompted an assessment of perioperative glucocorticoid administration.

Methods

We performed a cross-sectional survey of Canadian Pediatric Anesthesia Society (CPAS) and Canadian Pediatric Endocrine Group (CPEG) members via membership email lists to assess reported practice patterns to select clinical scenarios.

Results

Responses were collected from 49 anesthesiologists and 37 pediatric endocrinologists. Less than half of anesthesiologists reported they would provide stress dose corticosteroids for patients undergoing cystoscopy while a significant majority of pediatric endocrinologists reported they would recommend stress dose corticosteroid administration (45% vs 92% respectively, p < 0.0001). Twenty-one percent of anesthesiologists reported they would not provide stress dose corticosteroids for patients undergoing laparotomy. Pediatric endocrinologists reported they were more likely to refer to guidelines for management of stress dose steroids (84% vs 51%, p < 0.001), with many Canadian pediatric endocrinologists reporting to use institution specific guidelines.

Conclusions

Our results demonstrate a clear difference in the reported approach to perioperative stress dose steroids between pediatric anesthesiologists and pediatric endocrinologists which may impact patient care. Further dialogue is required to address this apparent discrepancy in practice patterns and future research is needed to provide evidence-based practice recommendations.

Electronic supplementary material

The online version of this article (10.1186/s13633-018-0063-4) contains supplementary material, which is available to authorized users.

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.

Preoperative optimization of patients with inflammatory bowel disease undergoing gastrointestinal surgery: a systematic review

PURPOSE

Surgical management of inflammatory bowel disease (IBD) is a challenging task. The aim of preoperative optimization (PO) is to decrease the risk of complications and reduce the length of postoperative stay. The aim of this study was to review and grade the available evidence, attain clear recommendations, and point out potential future research.

METHODS

Studies were identified from electronic databases (PubMed, Embase, and Cochrane Library) and scanning reference lists in relevant papers. English-written studies examining PO in adult patients with IBD were included. Eight PO factors were investigated.

RESULTS

Management of IBD is a multidisciplinary task. Steroid withdrawal is recommended while steroid stress dose is not recommended. Thiopurines appear to be safe, but it may be prudent to plan the procedure remotely from the last dose of an anti-TNF agent. Nutritional risk screening is recommended to unveil and correct any malnutrition. Thrombosis prophylaxis prior to surgery is well supported by evidence while extended 4-week prophylaxis needs further research. Percutaneous ultrasound or CT-guided drainage for intra-abdominal abscesses is recommended, but it is unclear for how long supplementary antibiotics (ABs) should be used. Oral AB 24 h prior to open surgery might improve outcome if given as complementary to IV perioperative AB. Mechanical bowel preparation is not supported by evidence. Comorbidities must be treated accordingly prior to surgical intervention. Smoking cessation can be beneficial for wound healing.

CONCLUSION

Multimodel PO intervention in IBD patients is recommended.

Dermatomyositis - key to diagnosing ovarian cancer, monitoring treatment and detecting recurrent disease: Case report

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Young women with dermatomyositis are at high risk for underlying ovarian cancer.

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Dermatomyositis symptoms can be used to assess treatment and recurrence of disease.

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Immunosuppression can complicate postoperative recovery in ovarian cancer patients.

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Ovarian cancer patients with dermatomyositis should have genetic testing.

Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era"

Crohn’s disease (CD) is characterized by transmural inflammation of the gastrointestinal tract leading to inflammatory, stricturing and/or and fistulizing disease. Once a patient develops medically refractory disease, mechanical obstruction, fistulizing disease or perforation, surgery is indicated. Unfortunately, surgery is not curative in most cases, underscoring the importance of bowel preservation and adequate perioperative medical management. As many of the medications used to treat CD are immunosuppressive, the concern for postoperative infectious complications and anastomotic healing are particularly concerning; these concerns have to be balanced with preventing and treating residual or recurrent disease. We herein review the available literature and make recommendations regarding the preoperative, perioperative and postoperative administration of immunosuppressive medications in the current era of biological therapy for CD. Standardized algorithms for perioperative medical management would greatly assist future research for optimizing surgical outcomes and preventing disease recurrence in the future.

Endocrinopathies: The current and changing perspectives in anesthesia practice

The gateways to advancements in medical fields have always been accessed through the coalition between various specialties. It is almost impossible for any specialty to make rapid strides of its own. However, the understanding of deeper perspectives of each specialty or super specialty is essential to take initiatives for the progress of the other specialty. Endocrinology and anesthesiology are two such examples which have made rapid progress in the last three decades. Somehow the interaction and relationship among these medical streams have been only scarcely studied. Diabetes and thyroid pathophysiologies have been the most researched endocrine disorders so far in anesthesia practice but even their management strategies have undergone significant metamorphosis over the last three decades. As such, anesthesia practice has been influenced vastly by these advancements in endocrinology. However, a comprehensive understanding of the relationship between these two partially related specialties is considered to be an essential cornerstone for further progress in anesthesia and surgical sciences. The current review is an attempt to imbibe the current and the changing perspectives so as to make the understanding of the relationship between these two medical streams a little simple and clearer.

Comparison of intervention effects in split-mouth and parallel-arm randomized controlled trials: a meta-epidemiological study

Background

Split-mouth randomized controlled trials (RCTs) are popular in oral health research. Meta-analyses frequently include trials of both split-mouth and parallel-arm designs to derive combined intervention effects. However, carry-over effects may induce bias in split- mouth RCTs. We aimed to assess whether intervention effect estimates differ between split- mouth and parallel-arm RCTs investigating the same questions.

Methods

We performed a meta-epidemiological study. We systematically reviewed meta- analyses including both split-mouth and parallel-arm RCTs with binary or continuous outcomes published up to February 2013. Two independent authors selected studies and extracted data. We used a two-step approach to quantify the differences between split-mouth and parallel-arm RCTs: for each meta-analysis. First, we derived ratios of odds ratios (ROR) for dichotomous data and differences in standardized mean differences (∆SMD) for continuous data; second, we pooled RORs or ∆SMDs across meta-analyses by random-effects meta-analysis models.

Results

We selected 18 systematic reviews, for 15 meta-analyses with binary outcomes (28 split-mouth and 28 parallel-arm RCTs) and 19 meta-analyses with continuous outcomes (28 split-mouth and 28 parallel-arm RCTs). Effect estimates did not differ between split-mouth and parallel-arm RCTs (mean ROR, 0.96, 95% confidence interval 0.52–1.80; mean ∆SMD, 0.08, -0.14–0.30).

Conclusions

Our study did not provide sufficient evidence for a difference in intervention effect estimates derived from split-mouth and parallel-arm RCTs. Authors should consider including split-mouth RCTs in their meta-analyses with suitable and appropriate analysis.

Hospital dental practice in special patients

Dental patients with special needs are people with different systemic diseases, multiple disorders or severe physical and/or mental disabilities. A Medline search was made, yielding a total of 29 articles that served as the basis for this study, which offers a brief description of the dental intervention protocols in medically compromised patients. Dental treatment in patients with special needs, whether presenting medical problems or disabilities, is sometimes complex. For this reason the hospital should be regarded as the ideal setting for the care of these individuals. Before starting any dental intervention, a correct patient evaluation is needed, based on a correct anamnesis, medical records and interconsultation reports, and with due assessment of the medical risks involved. The hospital setting offers the advantage of access to electronic medical records and to data referred to any complementary tests that may have been made, and we moreover have the possibility of performing treatments under general anesthesia. In this context, ambulatory major surgery is the best approach when considering general anesthesia in patients of this kind.

Key words:Hospital dentistry, special patients, medically compromised patients.