1
|
Feng Y, Chang P, Liu J, Zhang WS. Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review. J Clin Anesth 2024; 94:111367. [PMID: 38232466 DOI: 10.1016/j.jclinane.2023.111367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024]
Abstract
The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic-pituitary-adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: "adrenal insufficiency (AI)", "stress response inhibition", and "uncertainty". The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.
Collapse
Affiliation(s)
- Yan Feng
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, China; Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Pan Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China
| | - Wen-Sheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, China; Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, China.
| |
Collapse
|
2
|
Ebrahimi F, Andereggen L, Christ ER. Morbidities and mortality among hospitalized patients with hypopituitarism: Prevalence, causes and management. Rev Endocr Metab Disord 2024; 25:599-608. [PMID: 38802643 PMCID: PMC11162375 DOI: 10.1007/s11154-024-09888-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 05/29/2024]
Abstract
Hypopituitarism is a highly heterogeneous multisystem disorder that can have a major impact on long-term morbidity and mortality, but even more so during acute medical conditions requiring hospitalization. Recent studies suggest a significant in-hospital burden with prolonged length of stay, increased rate of intensive care unit (ICU) admission, and initiation of mechanical ventilation - all of which may lead to an increased risk of in-hospital mortality. On the one hand, patients with hypopituitarism are often burdened by metabolic complications, including obesity, hypertension, dyslipidemia, and hyperglycemia, which alone, or in combination, are known to significantly alter relevant physiological mechanisms, including metabolism, innate and adaptive immune responses, coagulation, and wound healing, thereby contributing to adverse in-hospital outcomes. On the other hand, depending on the extent and the number of pituitary hormone deficiencies, early recognition of hormone deficiencies and appropriate management and replacement strategy within a well-organized multidisciplinary team are even stronger determinants of short-term outcomes during acute hospitalization in this vulnerable patient population. This review aims to provide an up-to-date summary of recent advances in pathophysiologic understanding, clinical implications, and recommendations for optimized multidisciplinary management of hospitalized patients with hypopituitarism.
Collapse
Affiliation(s)
- Fahim Ebrahimi
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Basel, Basel, Switzerland.
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17177, Stockholm, Sweden.
- Department of Gastroenterology and Hepatology, Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland.
| | - Lukas Andereggen
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Emanuel R Christ
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
3
|
Syed H, Nadeem A, Gardinier D, Weekley K, Ribakow D, Lupe S, Bhat S, Holubar S, Cohen BL. Peri-Operative Optimization of Patients with Crohn's Disease. Curr Gastroenterol Rep 2024; 26:125-136. [PMID: 38421577 PMCID: PMC11081987 DOI: 10.1007/s11894-024-00925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach. RECENT FINDINGS Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.
Collapse
Affiliation(s)
- Hareem Syed
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ahmed Nadeem
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - David Gardinier
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kendra Weekley
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Dovid Ribakow
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephen Lupe
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Shubha Bhat
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Benjamin L Cohen
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| |
Collapse
|
4
|
Tsuang FY, Shih SR, Tseng HM, Wang HC. Perioperative growth hormone levels as an early predictor of new-onset secondary adrenal insufficiency following transsphenoidal pituitary tumor resection. Asian J Surg 2024; 47:1746-1755. [PMID: 38148260 DOI: 10.1016/j.asjsur.2023.12.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVE This study aims to predict new-onset secondary adrenal insufficiency (NOSAI) after transsphenoidal pituitary tumor resection surgery using perioperative growth hormone (GH) and prolactin (PRL) levels, among other factors. METHODS A cohort of 124 adult patients who underwent transsphenoidal resection for non-functioning pituitary adenoma, with routine perioperative glucocorticoid use, was used to develop the predictive regression model. An additional 46 patients served as the validation cohort. Generalized additive models were used to identify optimal cut-off points for the variables. RESULTS The GH level on postoperative day one (POD1) can be a simple predictor by implementing a cut-off point of 0.41 ng/ml. A value ≤ 0.41 ng/mL predicted NOSAI with 0.6316 sensitivity and 0.7810 specificity for the original cohort and 1.0000 sensitivity and 0.7143 specificity for the validation cohort. The multiple logistic regression model included perioperative PRL level difference, perioperative GH level difference, intraoperative cerebrospinal fluid (CSF) leakage, tumor size, and the combined effect of diabetes insipidus (DI) and relative perioperative GH level difference. The areas under the receiver operating characteristic curves were 0.9410 (original cohort) and 0.9494 (validation cohort) for the regression model. CONCLUSION Early morning GH level on POD1 can predict NOSAI with fair accuracy when perioperative stress dose glucocorticoid is administered. Prediction accuracy can be improved by considering CSF leakage, DI, and perioperative changes in GH and PRL in the final regression model.
Collapse
Affiliation(s)
- Fon-Yih Tsuang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Spine Tumor Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Shyang-Rong Shih
- Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ham-Min Tseng
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Huan-Chih Wang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Biological Science and Technology, College of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan; Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan.
| |
Collapse
|
5
|
Tian X, Zhao J, Song Y, Wang Q, Li M, Liu J, Zeng X. 2022 Chinese guideline for the management of pregnancy and reproduction in systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:115-138. [PMID: 37781682 PMCID: PMC10538620 DOI: 10.2478/rir-2023-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/19/2023] [Indexed: 10/03/2023]
Abstract
Systemic lupus erythematosus (SLE), a prevalent autoimmune disease predominantly affecting women of childbearing age, presents ongoing challenges despite notable advances in diagnosis and treatment. Although survival rates for SLE patients have significantly improved, pregnancy continues to pose a considerable obstacle. Addressing this critical need for enhanced reproductive and prenatal care, there is a pressing imperative to establish standardized protocols for peri-gestational monitoring and treatment in SLE patients. This guideline is jointly sponsored by the National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), the Chinese Systemic Lupus Erythematosus Treatment and Research Group (CSTAR), and the Chinese Research Committee of Pregnancy and Reproduction in Autoimmune Rheumatic Diseases (CHOPARD). Thirteen pertinent clinical questions have been generated through several rounds of rigorous clinical and methodological expert discussions and selections for a comprehensive understanding of key aspects in this domain. Guided by thorough examination of research evidence and expert perspectives, the formulated recommendations aim to optimize pregnancy success rates, reduce maternal and infant mortality rates, and ultimately enhance the overall well-being of SLE patients.
Collapse
Affiliation(s)
- Xinping Tian
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Yijun Song
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| | - Juntao Liu
- Department of Obstetrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences& Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science& Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College; Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing100730, China
| |
Collapse
|
6
|
Chen Cardenas SM, Santhanam P, Morris-Wiseman L, Salvatori R, Hamrahian AH. Perioperative Evaluation and Management of Patients on Glucocorticoids. J Endocr Soc 2022; 7:bvac185. [PMID: 36545644 PMCID: PMC9760550 DOI: 10.1210/jendso/bvac185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Indexed: 12/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Stanley M Chen Cardenas
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Prasanna Santhanam
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lilah Morris-Wiseman
- Division of Endocrine Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir H Hamrahian
- Correspondence: Amir Hamrahian, MD, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, 1830 E Monument St, Ste 333, Baltimore, MD 21287, USA.
| |
Collapse
|
7
|
Guo X, Zhang D, Pang H, Wang Z, Gao L, Wang Y, Ma W, Lian W, Xing B. Safety of Withholding Perioperative Hydrocortisone for Patients With Pituitary Adenomas With an Intact Hypothalamus-Pituitary-Adrenal Axis: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2242221. [PMID: 36383383 PMCID: PMC9669812 DOI: 10.1001/jamanetworkopen.2022.42221] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Pituitary adenoma is the second most common primary brain tumor. Perioperative hydrocortisone has been used for decades to avoid postoperative adrenal insufficiency. Recent studies suggest that withholding perioperative hydrocortisone may be safe for patients with an intact hypothalamus-pituitary-adrenal (HPA) axis. OBJECTIVE To assess the safety of withholding hydrocortisone during the perioperative period of pituitary adenoma surgery for patients with an intact HPA axis. DESIGN, SETTING, AND PARTICIPANTS A parallel-group, triple-masked, noninferiority randomized clinical trial was conducted at Peking Union Medical College Hospital from November 1, 2020, to January 31, 2022, among 436 patients aged 18 to 70 years with an intact HPA axis undergoing surgery for pituitary adenomas. INTERVENTIONS Hydrocortisone supplementation protocol (intravenous and subsequent oral hydrocortisone, using a taper program) or no-hydrocortisone protocol. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of new-onset adrenal insufficiency (morning cortisol level, <5 μg/dL with adrenal insufficiency-related symptoms) during the perioperative period (on the day of operation and the following 2 days). The secondary outcome was the incidence of adrenal insufficiency in postoperative month 3. Analysis was on an intention-to-treat basis. RESULTS Of the 436 eligible patients, 218 were randomly assigned to the hydrocortisone group (136 women [62.4%]; mean [SD] age, 45.4 [13.0] years) and 218 to the no-hydrocortisone group (128 women [58.7%]; mean [SD] age, 44.5 [13.8] years). All patients completed 3-month postoperative follow-up. The incidence of new-onset adrenal insufficiency during the perioperative period was 11.0% (24 of 218; 95% CI, 6.9%-15.2%) in the no-hydrocortisone group and 6.4% (14 of 218; 95% CI, 3.2%-9.7%) in the hydrocortisone group, with a difference of 4.6% (95% CI, -0.7% to 9.9%), meeting the prespecified noninferiority margin of 10 percentage points. The incidence of adrenal insufficiency at the 3-month follow-up was 3.7% (8 of 218) in the no-hydrocortisone group and 3.2% (7 of 218) in the hydrocortisone group (difference, 0.5%; 95% CI, -3.0% to 3.9%). Incidences of new-onset diabetes mellitus (1 of 218 [0.5%] vs 9 of 218 [4.1%]), hypernatremia (9 of 218 [4.1%] vs 21 of 218 [9.6%]), hypokalemia (23 of 218 [10.6%] vs 34 of 218 [15.6%]), and hypocalcemia (6 of 218 [2.8%] vs 19 of 218 [8.7%]) were lower in the no-hydrocortisone group than in the hydrocortisone group. Lower preoperative morning cortisol levels were associated with higher risks of the primary event (<9.3 µg/dL; odds ratio, 3.0; 95% CI, 1.5-5.9) and the secondary event (<8.8 µg/dL; odds ratio, 7.8; 95% CI, 2.6-23.4) events. CONCLUSIONS AND RELEVANCE This study found that withholding hydrocortisone was safe and demonstrated noninferiority to the conventional hydrocortisone supplementation regimen regarding the incidence of new-onset adrenal insufficiency among patients with an intact HPA axis undergoing pituitary adenomectomy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04621565.
Collapse
Affiliation(s)
- Xiaopeng Guo
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Duoxing Zhang
- Peking Union Medical College, Tsinghua University, Dongcheng District, Beijing, China
| | - Haiyu Pang
- Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Zihao Wang
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Lu Gao
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Yu Wang
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Wenbin Ma
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Wei Lian
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Dongcheng District, Beijing, China
| |
Collapse
|
8
|
Gaw AG, Wemyss C, Bell A, Goodall CA. Management of patients at risk of adrenal crisis in the dental setting: a review of current practice in UK dental teaching hospitals. Br Dent J 2022:10.1038/s41415-022-4515-0. [PMID: 35931749 DOI: 10.1038/s41415-022-4515-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/06/2022] [Indexed: 11/09/2022]
Abstract
Introduction Patients with impaired corticosteroid response due to Addison's disease or systemic glucocorticoid use are at risk of adrenal crisis when undergoing dental treatment. There is a lack of conclusive evidence to support dental teams in identifying patients at risk and their management to prevent an adrenal crisis.Aim To review the current practice in UK dental teaching hospitals regarding the management of patients at risk of adrenal crisis in the dental setting.Methods An electronic survey focused on patients who may be at risk of adrenal crisis due to systemic glucocorticoid therapy was sent to all 18 UK dental teaching hospitals. Information on the use of a policy or guidance was requested. Responses were evaluated for clinical decision-making, patient risk assessment and steroid cover dosing regimens.Results A 78% response rate was achieved. Only 29% of institutions had a written policy or guidance document. Variation exists in the threshold of steroid dose and duration of treatment in identifying patients at risk of adrenal suppression. Furthermore, the dose regime for steroid cover varied.Conclusion Further evidence on the management of patients at risk of adrenal crisis is required to inform national guidance and reduce variation in patient management.
Collapse
Affiliation(s)
- A Gemma Gaw
- Dental Core Trainee in Oral and Maxillofacial Surgery, Forth Valley Royal Hospital, Larbert, UK.
| | - Callum Wemyss
- Speciality Registrar in Oral Surgery, Glasgow Dental Hospital and School, Glasgow, UK
| | - Aileen Bell
- Professor of Oral Surgery and Dental Education, Honorary Consultant in Oral Surgery and Head of Dental School, School of Medicine Dentistry and Nursing, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Christine A Goodall
- Professor of Oral Surgery and Violence Reduction, Honorary Consultant in Oral Surgery, School of Medicine Dentistry and Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| |
Collapse
|
9
|
The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism. Ann Surg 2022; 276:e141-e176. [PMID: 35848728 DOI: 10.1097/sla.0000000000005522] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism. BACKGROUND Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT. METHODS Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.
Collapse
|
10
|
Endocrine and Electrolyte Disorders. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00040-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
|
11
|
Galati A, Brown ES, Bove R, Vaidya A, Gelfand J. Glucocorticoids for therapeutic immunosuppression: Clinical pearls for the practicing neurologist. J Neurol Sci 2021; 430:120004. [PMID: 34598056 DOI: 10.1016/j.jns.2021.120004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022]
Abstract
Given widespread use of glucocorticoid therapy in neurologic disease, understanding glucocorticoid pharmacology and risk is paramount for the practicing neurologist. While dosing and tapering regimens vary depending on the neurological disease and indication being treated, there are important general principles of glucocorticoid prescribing and monitoring that can guide clinical decision-making. Glucocorticoid-related toxicities can occur across multiple organ systems, including hypertension; dyslipidemia; weight gain; hyperglycemia; osteoporosis and avascular necrosis; myopathy; gastrointestinal bleeding; infection; and neuropsychiatric effects with sleep, mood disturbance and cognition. This narrative review provides a practical framework for safe and responsible prescribing of this therapeutic class of medications, including appreciation of immunosuppressive consequences, risk mitigation strategies, dosing and tapering, and recognition of adrenal insufficiency and glucocorticoid withdrawal.
Collapse
Affiliation(s)
- Alexandra Galati
- Division of Neuroimmunology and Glial Biology, Department of Neurology, University of California, San Francisco, USA.
| | - E Sherwood Brown
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Riley Bove
- Division of Neuroimmunology and Glial Biology, Department of Neurology, University of California, San Francisco, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jeffrey Gelfand
- Division of Neuroimmunology and Glial Biology, Department of Neurology, University of California, San Francisco, USA.
| |
Collapse
|
12
|
Lousada LM, Mendonca BB, Bachega TASS. Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:488-494. [PMID: 34283908 PMCID: PMC10522175 DOI: 10.20945/2359-3997000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/18/2021] [Indexed: 11/23/2022]
Abstract
Primary adrenal insufficiency (PAI) is characterized by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids. Addison's disease (AD) and congenital adrenal hyperplasia (CAH) are the most frequent disorders in adults and children, respectively. Despite the diagnostic advances and the availability of glucocorticoid and mineralocorticoid replacements, adrenal crisis (AC) is still a potentially lethal condition contributing to the increased mortality, not only during the first year of life, but also throughout life. Failure in increasing glucocorticoid doses during acute stress, when greater amounts of glucocorticoids are required, can lead to AC and an increase morbimortality rate of PAI. Considering a mortality rate of 0.5 per 100 patient years, up to 1,500 deaths from AC are expected in Brazil in the coming decade, which represents an alarming situation. The major clinical features are hypotension and volume depletion. Nonspecific symptoms such as fatigue, lack of energy, anorexia, nausea, vomiting, and abdominal pain are common. The main precipitating factors are gastrointestinal diseases, other infectious disease, stressful events (e.g., major pain, surgery, strenuous physical activity, heat, and pregnancy), and withdrawal of glucocorticoid therapy. Suspected AC requires immediate therapeutic action with intravenous (iv) hydrocortisone, fluid infusion, monitoring support, and antibiotics if necessary. AC is best prevented through patient education, precocious identification and by adjusting the glucocorticoid dosage in stressor situations. The emergency card, warning about acute glucocorticoid replacement, has high value in reducing the morbidity and mortality of AC.
Collapse
Affiliation(s)
- Lia Mesquita Lousada
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
13
|
Chan MH. Update on Management of the Oral and Maxillofacial Surgery Patient on Corticosteroids. Oral Maxillofac Surg Clin North Am 2021; 34:115-126. [PMID: 34711466 DOI: 10.1016/j.coms.2021.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Corticosteroids have been the cornerstone for treatment of many inflammatory and immune disorders with these beneficial effects well recognized by the medical community. It also possesses many undesirable clinical adverse effects that can occur within 2 weeks of use. Moreover, in the past decade, chronic users of corticosteroids have been linked to skeletal (vertebral and hip) osteoporosis/osteonecrosis with some patients requiring adjunctive antiresprotive medications to counteract fracture prevention. Additionally, two case reports have implicated daily prednisone user to cause osteonecrosis of the mandible. This chapter highlights current adrenal suppression classifications, pathophysiology, drug interactions, and perioperative surgical and anesthesia management.
Collapse
Affiliation(s)
- Michael H Chan
- Oral & Maxillofacial Surgery, Department of Veterans Affairs, New York Harbor Healthcare System (Brooklyn Campus), 800 Poly Place (Bk-160), Brooklyn, NY 11209, USA; Oral & Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 DeKalb Avenue (Box-187), Brooklyn, NY 11201, USA.
| |
Collapse
|
14
|
Ahmet A, Rowan-Legg A, Pancer L. Adrenal suppression from exogenous glucocorticoids: Recognizing risk factors and preventing morbidity. Paediatr Child Health 2021; 26:242-254. [PMID: 34630779 DOI: 10.1093/pch/pxab015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/12/2022] Open
Abstract
Adrenal suppression (AS), a potential side effect of glucocorticoid therapy (including inhaled corticosteroids), can be associated with significant morbidity and even death. In Canada, adrenal crisis secondary to AS continues to be reported in children. Being aware of symptoms associated with AS, understanding the risk factors for developing this condition, and familiarity with potential strategies to reduce risks associated with AS, are essential starting points for any clinician prescribing glucocorticoids.
Collapse
Affiliation(s)
- Alexandra Ahmet
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Anne Rowan-Legg
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| | - Larry Pancer
- Canadian Paediatric Society, Community Paediatrics Committee and Canadian Pediatric Endocrine Group, Ottawa, Ontario, Canada
| |
Collapse
|
15
|
Heath C, Siafarikas A, Sommerfield A, Ungern‐Sternberg BS. Peri-operative steroid management in the paediatric population. Acta Anaesthesiol Scand 2021; 65:1187-1194. [PMID: 34263943 DOI: 10.1111/aas.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids. METHODS A comprehensive literature search was conducted to construct a narrative review. RESULTS The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population. CONCLUSION The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.
Collapse
Affiliation(s)
- Chloe Heath
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
| | - Aris Siafarikas
- Department of Paediatric Endocrinology Perth Children’s Hospital Perth Western Australia Australia
- Faculty of Medicine, Paediatrics The University of Western Australia Nedlands Western Australia Australia
- Institute for Health ResearchUniversity of Notre Dame Fremantle Western Australia Australia
- Telethon Kids Institute Perth Western Australia Australia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
- Perioperative Medicine Team Telethon Kids Institute Perth Western Australia Australia
| | - Britta S. Ungern‐Sternberg
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
- Perioperative Medicine Team Telethon Kids Institute Perth Western Australia Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine Medical School The University of Western Australia Perth Western Australia Australia
| |
Collapse
|
16
|
Alexander TD, Collopy S, Yu S, Karsy M, Chitguppi C, Farrell CJ, Evans JJ. Perioperative Outcomes of a Hydrocortisone Protocol after Endonasal Surgery for Pituitary Adenoma Resection. Skull Base Surg 2021; 83:383-389. [DOI: 10.1055/s-0041-1735588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
Abstract
Introduction In pituitary adenomas (PAs), the use of postoperative steroid supplementation remains controversial, as it reduces peritumoral edema and sinonasal complaints but disrupts the detection of adrenal insufficiency (AI). It is unclear whether postoperative cortisol supplementation has a measurable effect on improving outcomes in patients with pituitary adenoma undergoing endoscopic transsphenoidal surgery (ETS). The objective of the study was to evaluate a postoperative steroid treatment protocol on various surgical outcomes in patients with PA undergoing ETS.
Methods A retrospective cohort study was performed for patients undergoing ETS from 2005 to 2020 for PA at a single tertiary academic center. Patients were divided into two groups: those managed by a routine postoperative glucocorticoid supplementation protocol (steroid protocol) and those who received supplementation based on postoperative cortisol laboratory assessment (steroid sparing protocol). Management was otherwise the same between groups. Evaluation of length of stay (LOS), sinonasal outcomes, 30-day readmission, and perioperative complications, including AI, were performed.
Results Among 535 patients, 21% (n = 111) received postoperative steroids, while the remainder (n = 424) did not. There were no differences in mean LOS (3 vs. 3 days, p = 0.72), sinonasal complaints (27 vs. 19%, p = 0.12), 30-day readmission (5% vs. 5%, p = 0.44), and perioperative complications (5 vs. 5%, p = 0.79) between both the groups. A multivariate model supported that both groups were comparable in predicting LOS, 30-day readmission, and complications. No reduction in readmission for AI was seen.
Conclusion Routine administration of postoperative glucocorticoids did not significantly improve patient outcomes in patients with PA who underwent ETS.
Collapse
Affiliation(s)
- Tyler D. Alexander
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Sarah Collopy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Siyuan Yu
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Michael Karsy
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Chandala Chitguppi
- Department of Otolaryngology and Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - Christopher J. Farrell
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| | - James J. Evans
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United Sates
| |
Collapse
|
17
|
Coccolini F, Improta M, Sartelli M, Rasa K, Sawyer R, Coimbra R, Chiarugi M, Litvin A, Hardcastle T, Forfori F, Vincent JL, Hecker A, Ten Broek R, Bonavina L, Chirica M, Boggi U, Pikoulis E, Di Saverio S, Montravers P, Augustin G, Tartaglia D, Cicuttin E, Cremonini C, Viaggi B, De Simone B, Malbrain M, Shelat VG, Fugazzola P, Ansaloni L, Isik A, Rubio I, Kamal I, Corradi F, Tarasconi A, Gitto S, Podda M, Pikoulis A, Leppaniemi A, Ceresoli M, Romeo O, Moore EE, Demetrashvili Z, Biffl WL, Wani I, Tolonen M, Duane T, Dhingra S, DeAngelis N, Tan E, Abu-Zidan F, Ordonez C, Cui Y, Labricciosa F, Perrone G, Di Marzo F, Peitzman A, Sakakushev B, Sugrue M, Boermeester M, Nunez RM, Gomes CA, Bala M, Kluger Y, Catena F. Acute abdomen in the immunocompromised patient: WSES, SIS-E, WSIS, AAST, and GAIS guidelines. World J Emerg Surg 2021; 16:40. [PMID: 34372902 PMCID: PMC8352154 DOI: 10.1186/s13017-021-00380-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/18/2021] [Indexed: 02/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Federico Coccolini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Mario Improta
- grid.8982.b0000 0004 1762 5736Emergency Department, Pavia University Hospital, Pavia, Italy
| | | | - Kemal Rasa
- Department of Surgery, Anadolu Medical Center, Kocaali, Turkey
| | - Robert Sawyer
- grid.268187.20000 0001 0672 1122General Surgery Department, Western Michigan University, Kalamazoo, MI USA
| | - Raul Coimbra
- grid.488519.90000 0004 5946 0028Department of General Surgery, Riverside University Health System Medical Center, Moreno Valley, CA USA
| | - Massimo Chiarugi
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Andrey Litvin
- grid.410686.d0000 0001 1018 9204Department of Surgical Disciplines, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Timothy Hardcastle
- Emergency and Trauma Surgery, Inkosi Albert Luthuli Central Hospital, Mayville, South Africa
| | - Francesco Forfori
- grid.144189.10000 0004 1756 8209Intensive Care Unit, Pisa University Hospital, Pisa, Italy
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Departement of Intensive Care, Erasme Univ Hospital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Andreas Hecker
- grid.411067.50000 0000 8584 9230Departementof General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Richard Ten Broek
- grid.10417.330000 0004 0444 9382General Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luigi Bonavina
- grid.416351.40000 0004 1789 6237General Surgery, San Donato Hospital, Milano, Italy
| | - Mircea Chirica
- grid.450307.5General Surgery, CHUGA-CHU Grenoble Alpes UGA-Université Grenoble Alpes, Grenoble, France
| | - Ugo Boggi
- grid.144189.10000 0004 1756 8209General Surgery, Pisa University Hospital, Pisa, Italy
| | - Emmanuil Pikoulis
- grid.5216.00000 0001 2155 08003rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Salomone Di Saverio
- grid.18887.3e0000000417581884General Surgery, Varese University Hospital, Varese, Italy
| | - Philippe Montravers
- grid.411119.d0000 0000 8588 831XDépartement d’Anesthésie-Réanimation, CHU Bichat Claude Bernard, Paris, France
| | - Goran Augustin
- grid.4808.40000 0001 0657 4636Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Dario Tartaglia
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Enrico Cicuttin
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Camilla Cremonini
- grid.144189.10000 0004 1756 8209General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisa, 2, 56124 Pisa, Italy
| | - Bruno Viaggi
- grid.24704.350000 0004 1759 9494ICU Department, Careggi University Hospital, Firenze, Italy
| | - Belinda De Simone
- grid.418056.e0000 0004 1765 2558Department of Digestive, Metabolic and Emergency Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy/Saint Germain en Laye, Saint Germain en Laye, France
| | - Manu Malbrain
- grid.8767.e0000 0001 2290 8069Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel, Brussels, Belgium
| | - Vishal G. Shelat
- General and Emergency Surgery, Tan Tock Seng Hospital, Kuala Lumpur, Malaysia
| | - Paola Fugazzola
- grid.8982.b0000 0004 1762 5736General and Emergency Surgery, Pavia University Hospital, Pavia, Italy
| | - Luca Ansaloni
- grid.8982.b0000 0004 1762 5736General and Emergency Surgery, Pavia University Hospital, Pavia, Italy
| | - Arda Isik
- grid.411776.20000 0004 0454 921XGeneral Surgery, School of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ines Rubio
- grid.81821.320000 0000 8970 9163Department of General Surgery, La Paz University Hospital, Madrid, Spain
| | - Itani Kamal
- grid.38142.3c000000041936754XGeneral Surgery, VA Boston Health Care System, Boston University, Harvard Medical School, Boston, MA USA
| | - Francesco Corradi
- grid.144189.10000 0004 1756 8209Intensive Care Unit, Pisa University Hospital, Pisa, Italy
| | - Antonio Tarasconi
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| | - Stefano Gitto
- grid.8404.80000 0004 1757 2304Gastroenterology and Transplant Unit, Firenze University Hospital, Firenze, Italy
| | - Mauro Podda
- grid.7763.50000 0004 1755 3242General and Emergency Surgery, Cagliari University Hospital, Cagliari, Italy
| | - Anastasia Pikoulis
- grid.5216.00000 0001 2155 0800Medical Department, National & Kapodistrian University of Athens, Athens, Greece
| | - Ari Leppaniemi
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Marco Ceresoli
- grid.18887.3e0000000417581884General Surgery, Monza University Hospital, Monza, Italy
| | - Oreste Romeo
- grid.268187.20000 0001 0672 1122Department of Surgery, Western Michigan University School of Medicine, Kalamazoo, MI USA
| | - Ernest E. Moore
- grid.239638.50000 0001 0369 638XTrauma Surgery, Denver Health, Denver, CL USA
| | - Zaza Demetrashvili
- grid.412274.60000 0004 0428 8304General Surgery, Tbilisi State Medical University, Tbilisi, Georgia
| | - Walter L. Biffl
- grid.415402.60000 0004 0449 3295Emergency and Trauma Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Imitiaz Wani
- General Surgery, Government Gousia Hospital, Srinagar, Kashmir India
| | - Matti Tolonen
- grid.15485.3d0000 0000 9950 5666Abdominal Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | | | - Sameer Dhingra
- National Institute of Pharmaceutical Education and Research, Hajipur (NIPER-H), Vaishali, Bihar India
| | - Nicola DeAngelis
- grid.50550.350000 0001 2175 4109General Surgery Department, Henry Mondor University Hospital, Paris, France
| | - Edward Tan
- grid.10417.330000 0004 0444 9382Emergency Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Fikri Abu-Zidan
- General Surgery, UAE University Hospital, Sharjah, United Arab Emirates
| | - Carlos Ordonez
- grid.8271.c0000 0001 2295 7397Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Universidad del Valle, Cali, Colombia
| | - Yunfeng Cui
- grid.265021.20000 0000 9792 1228Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Gennaro Perrone
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| | | | - Andrew Peitzman
- grid.21925.3d0000 0004 1936 9000General Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital St George Plovdiv, Plovdiv, Bulgaria
| | - Michael Sugrue
- General Surgery, Letterkenny Hospital, Letterkenny, Ireland
| | - Marja Boermeester
- grid.5650.60000000404654431Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | - Carlos Augusto Gomes
- Department of Surgery, Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Hospital Universitário Terezinha de Jesus, Juiz de Fora, Brazil
| | - Miklosh Bala
- grid.17788.310000 0001 2221 2926General Surgery, Hadassah Hospital, Jerusalem, Israel
| | - Yoram Kluger
- General Sugery, Ramabam Medical Centre, Tel Aviv, Israel
| | - Fausto Catena
- grid.411482.aGeneral Surgery, Parma University Hospital, Parma, Italy
| |
Collapse
|
18
|
Ahmet A, Rowan-Legg A, Pancer L. La suppression surrénalienne causée par les glucocorticoïdes exogènes : en reconnaître les facteurs de risque et en prévenir les effets. Paediatr Child Health 2021; 26:248-254. [PMID: 34136054 DOI: 10.1093/pch/pxab016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 06/08/2020] [Indexed: 11/14/2022] Open
Abstract
Résumé
La suppression surrénalienne, un effet secondaire potentiel du traitement aux glucocorticoïdes (y compris les corticostéroïdes inhalés), peut avoir des conséquences graves et même fatales. Au Canada, on continue de déclarer des poussées d’insuffisance corticosurrénalienne consécutives à une suppression surrénalienne chez les enfants. Avant de prescrire des glucocorticoïdes, le clinicien doit absolument connaître les symptômes de suppression surrénalienne, comprendre les facteurs de risque de cette affection et être au courant des stratégies susceptibles d’en réduire les risques.
Collapse
Affiliation(s)
- Alexandra Ahmet
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Anne Rowan-Legg
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| | - Larry Pancer
- Société canadienne de pédiatrie, comité de la pédiatrie communautaire et Groupe canadien d'endocrinologie pédiatrique, Ottawa (Ontario), Canada
| |
Collapse
|
19
|
Saunders NE, Holmes JR, Walton DM, Talusan PG. Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202106000-00002. [PMID: 34101706 DOI: 10.2106/jbjs.rvw.20.00201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery. » For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld. » Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug. » For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing. » In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.
Collapse
Affiliation(s)
- Noah E Saunders
- The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - James R Holmes
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - David M Walton
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul G Talusan
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
| |
Collapse
|
20
|
Zhou W, Zhang WJ, Zhao GQ, Li K. Bone cement implantation syndrome during hip replacement in a patient with pemphigus and Parkinson’s disease: A case report. World J Clin Cases 2021; 9:3342-3349. [PMID: 34002143 PMCID: PMC8107892 DOI: 10.12998/wjcc.v9.i14.3342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/22/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Bone cement implantation syndrome (BCIS) is characterized by hypotension, arrhythmia, diffuse pulmonary microvascular embolism, shock, cardiac arrest, any combination of these factors, or even death following bone cement implantation.
CASE SUMMARY An 80-year-old patient with pemphigus and Parkinson’s disease underwent total hip replacement under spinal subarachnoid block and developed acute pulmonary embolism after bone cement implantation. The patient received mask mechanical ventilation with a continuous intravenous infusion of adrenaline (2 μg/mL) at a rate of 30 mL/h. Subsequently, the symptoms of BCIS were markedly alleviated, and the infusion rate of adrenaline was gradually reduced until the infusion was completely stopped 45 min later. The patient was then transferred to the Department of Orthopedics, and anticoagulation therapy began at 12 h postoperatively. No other complications were observed.
CONCLUSION This is a rare case of BCIS in a high-risk patient with pemphigus and Parkinson’s disease.
Collapse
Affiliation(s)
- Wei Zhou
- Department of Anesthesiology, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Wen-Jing Zhang
- Department of Anesthesiology, China Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Qing Zhao
- Department of Anesthesiology, China Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Kai Li
- Department of Anesthesiology, China Japan Union Hospital of Jilin University, Changchun 130021, Jilin Province, China
| |
Collapse
|
21
|
Fischli S, von Wyl V, Wuillemin W, von Känel R, Schütz P, Christ-Crain M, Studer F, Brander L, Schüpfer G, Metzger J, Henzen C. Impact of Adrenal Function on Hemostasis/Endothelial Function in Patients Undergoing Surgery. J Endocr Soc 2021; 5:bvab047. [PMID: 33928206 PMCID: PMC8057135 DOI: 10.1210/jendso/bvab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 11/19/2022] Open
Abstract
Context Glucocorticoids regulate hemostatic and endothelial function, and they are critical for adaptive functions during surgery. No data regarding the impact of adrenal function on hemostasis and endothelial function in the perioperative setting are available. Objective We assessed the association of adrenal response to adrenocorticotropic hormone (ACTH) and markers of endothelial/hemostatic function in surgical patients. Methods This prospective observational study, conducted at a tertiary care hospital, included 60 patients (35 male/25 female) undergoing abdominal surgery. Adrenal function was evaluated by low-dose ACTH stimulation test on the day before, during, and the day after surgery. According to their stimulated cortisol level (cutoff ≥ 500 nmol/L), patients were classified as having normal hypothalamic-pituitary-adrenal (HPA)-axis function (nHPA) or deficient HPA-axis function (dHPA). Parameters of endothelial function (soluble vascular cell adhesion molecule-1, thrombomodulin) and hemostasis (fibrinogen, von Willebrand factor antigen, factor VIII [FVIII]) were measured during surgery. Results Twenty-one patients had dHPA and 39 had nHPA. Compared with nHPA, patients with dHPA had significantly lower peak cortisol before (median 568 vs 425 nmol/L, P < 0.001) and during (693 vs 544 nmol/L, P < 0.001) surgery and lower postoperative hemoglobin levels (116 g/L vs 105 g/L, P = 0.049). FVIII was significantly reduced in patients with dHPA in uni- and multivariable analyses; other factors displayed no significant differences. Coagulation factors/endothelial markers changed progressively in relation to stimulated cortisol levels and showed a turning point at cortisol levels between 500 and 600 nmol/L. Conclusions Patients with dHPA undergoing abdominal surgery demonstrate impaired hemostasis which can translate into excessive blood loss.
Collapse
Affiliation(s)
- Stefan Fischli
- Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Viktor von Wyl
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8006 Zurich, Switzerland
| | - Walter Wuillemin
- Division of Hematology, Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Roland von Känel
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Philipp Schütz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Mirjam Christ-Crain
- Division of Endocrinology, Diabetes, and Metabolism, University Hospital Basel, 4031 Basel, Switzerland
| | - Fabian Studer
- Department of Internal Medicine, Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Lukas Brander
- Department of Internal Medicine, Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Guido Schüpfer
- Division of Anesthesiology, Luzerner Kantonsspital, 6000 Luzern,Switzerland
| | - Jürg Metzger
- Division of Visceral Surgery, Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Christoph Henzen
- Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, 6000 Luzern, Switzerland.,Department of Internal Medicine, Luzerner Kantonsspital, 6000 Luzern, Switzerland
| |
Collapse
|
22
|
Seo KH. Perioperative glucocorticoid management based on current evidence. Anesth Pain Med (Seoul) 2021; 16:8-15. [PMID: 33445232 DOI: 10.17085/apm.20089] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/30/2020] [Indexed: 01/04/2023] Open
Abstract
Glucocorticoid preparations, adreno-cortical steroids, with strong anti-inflammatory and immunosuppressive effects, are widely used for treating various diseases. The number of patients exposed to steroid therapy prior to surgery is increasing. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative steroid supplementation. Stress-dose glucocorticoid administration is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. Therefore, glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress by evaluating the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis. Various textbooks and research articles recommend the stress-dose of glucocorticoids during perioperative periods. It has been commonly suggested that glucocorticoids should be administered in an amount equivalent to about 100 mg of cortisol for major surgery because it induces approximately 5 times the normal secretion. However, more studies, with appropriate power, regarding the administration of stress-dose glucocorticoids are still required, and evaluation of patients with possible adrenal insufficiency and appropriate glucocorticoid administration based on surgical stress will help improve the prognosis.
Collapse
Affiliation(s)
- Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Korea
| |
Collapse
|
23
|
Himes CP, Ganesh R, Wight EC, Simha V, Liebow M. Perioperative Evaluation and Management of Endocrine Disorders. Mayo Clin Proc 2020; 95:2760-2774. [PMID: 33168157 DOI: 10.1016/j.mayocp.2020.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
Collapse
Affiliation(s)
- Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Vinaya Simha
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Mark Liebow
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
24
|
Abstract
Supplemental Digital Content is available in the text. In patients with septic shock, hydrocortisone 200–400 mg/d has been shown to reverse shock compared with placebo. Lower doses of hydrocortisone have not previously been studied, and there are no previous studies comparing two different doses of hydrocortisone. At our institution, some clinicians routinely prescribe doses less than 200 mg/d. This study aims to compare the effect of lower doses of hydrocortisone to standard doses on shock reversal and adverse events in septic shock.
Collapse
|
25
|
Arafah BM. Perioperative Glucocorticoid Therapy for Patients with Adrenal Insufficiency: Dosing Based on Pharmacokinetic Data. J Clin Endocrinol Metab 2020; 105:5717686. [PMID: 31996925 DOI: 10.1210/clinem/dgaa042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/28/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Perioperative glucocorticoid therapy for patients with adrenal insufficiency (AI) is currently based on anecdotal reports, without supporting pharmacokinetic data. METHODS We determined the half-life, clearance, and volume of distribution of 2 consecutive intravenously (IV)-administered doses of hydrocortisone (15 or 25 mg every 6 hours) to 22 dexamethasone-suppressed healthy individuals and used the data to develop a novel protocol to treat 68 patients with AI who required surgical procedures. Patients received 20 mg of hydrocortisone orally 2 to 4 hours before intubation and were started on 25 mg of IV hydrocortisone every 6 hours for 24 hours and 15 mg every 6 hours during the second day. Nadir cortisol concentrations were repeatedly measured during that period. RESULTS In healthy individuals, cortisol half-life was longer when the higher hydrocortisone dose was administered (2.02 ± 0.15 vs 1.81 ± 0.11 hours; P < 0.01), and in patients with AI, the half-life was longer than in healthy individuals given the same hydrocortisone dose. In both populations, the cortisol half-life increased further with the second hormone injection. Prolongation of cortisol half-life was due to decreased hydrocortisone clearance and an increase in its volume of distribution. Nadir cortisol levels determined throughout the 48 postoperative hours were within the range of values and often exceeded those observed perioperatively in patients without adrenal dysfunction. CONCLUSIONS Cortisol pharmacokinetics are altered in the postoperative period and indicate that lower doses of hydrocortisone can be safely administered to patients with AI undergoing major surgery. The findings of this investigation call into question the current practice of administering excessive glucocorticoid supplementation during stress.
Collapse
Affiliation(s)
- Baha M Arafah
- Division of Clinical and Molecular Endocrinology, Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
26
|
Betterle C, Presotto F, Furmaniak J. Epidemiology, pathogenesis, and diagnosis of Addison's disease in adults. J Endocrinol Invest 2019; 42:1407-1433. [PMID: 31321757 DOI: 10.1007/s40618-019-01079-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Addison's disease (AD) is a rare disorder and among adult population in developed countries is most commonly caused by autoimmunity. In contrast, in children genetic causes are responsible for AD in the majority of patients. PURPOSE This review describes epidemiology, pathogenesis, genetics, natural history, clinical manifestations, immunological markers and diagnostic strategies in patients with AD. Standard care treatments including the management of patients during pregnancy and adrenal crises consistent with the recent consensus statement of the European Consortium and the Endocrine Society Clinical Practice Guideline are described. In addition, emerging therapies designed to improve the quality of life and new strategies to modify the natural history of autoimmune AD are discussed. CONCLUSIONS Progress in optimizing replacement therapy for patients with AD has allowed the patients to lead a normal life. However, continuous education of patients and health care professionals of ever-present danger of adrenal crisis is essential to save lives of patients with AD.
Collapse
Affiliation(s)
- C Betterle
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy
| | - F Presotto
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Via Ospedale Civile 105, 35128, Padua, Italy.
- Unit of Internal Medicine, Ospedale dell'Angelo, via Paccagnella 11, 30174, Mestre-Venice, Italy.
| | | |
Collapse
|
27
|
Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 16:118-123. [PMID: 31708984 PMCID: PMC6836633 DOI: 10.5114/kitp.2019.88600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 09/20/2019] [Indexed: 12/02/2022]
Abstract
Introduction Cortisol level affects the prognosis of patients after cardiac surgery. Meanwhile, there are no clear guidelines for steroid supplementation after a cardiac operation. The relationship between age and blood cortisol levels has not been finally clarified. Aim Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery. Material and methods The study included 20 patients of both sexes referred for cardiac surgery. A short ACTH synthetic stimulation test was carried out. Assessment of cortisol secretion was carried out in the morning on the day of surgery and the 1st, 2nd and 4th days after surgery in blood samples. Results A result within the normal range for the adrenal reserve was found in 19 of the 20 patients enrolled in the study. The short Synacthen test predicted postoperative secretion of cortisol (p = 0.04, r = 0.047). A relationship between secretion of cortisol and patients’ age was observed (p = 0.03, r = 0.48). The concentration of cortisol on the 1st postoperative day was correlated with the total dose of dopamine (p = 0.006, r = 0.58) and adrenaline (p = 0.04, r = 0.47). The concentration of cortisol on the day of the surgery correlated with the lactate concentration on day 2 (p = 0.04, r = 0.45). The concentration of lactates on day 1 correlated with total dose of dopamine (p = 0.01, r = 0.54). Conclusions A short Synacthen test allows one to predict secretion of cortisol after cardiac surgery. Greater secretion of cortisol after cardiac surgery may be associated with a more difficult postoperative course. There was no decrease in cortisol secretion with age.
Collapse
|
28
|
Kadam SV, Tailor KB, Joshi VH, Rao SG. Preoperative adrenal insufficiency in a neonate with congenital heart disease surgery. Ann Pediatr Cardiol 2019; 12:351-353. [PMID: 31516305 PMCID: PMC6716307 DOI: 10.4103/apc.apc_108_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Shankar Vithalrao Kadam
- Department of Pediatric Cardiac Intensive Care, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India. E-mail:
| | - Kamlesh B Tailor
- Department of Pediatric Cardiac Intensive Care, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India. E-mail:
| | - Vinay Hk Joshi
- Department of Pediatric Cardiac Intensive Care, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India. E-mail:
| | - Suresh G Rao
- Department of Pediatric Cardiac Intensive Care, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India. E-mail:
| |
Collapse
|
29
|
Abstract
Although removal of pituitary tumors yields excellent surgical outcomes, perturbations in the hypothalamic-pituitary axis are not uncommon. Careful assessment of postoperative hormone status with supplementation or further medical therapy is critical to successful outcomes. Although many centers routinely use perioperative steroids, they can be associated with worse outcomes in the absence of intact preoperative adrenal function or damage to the pituitary gland or stalk during surgery. Postoperative assessment of prolactin, cortisol, and growth hormone can be prognostic of surgical cure. Hormonal axes should be reevaluated routinely several weeks after surgery, because longitudinal monitoring is important for surgical and medical outcomes.
Collapse
Affiliation(s)
- Anshu Buttan
- Department of Medicine, Division of Endocrinology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker B-131, Los Angeles, CA 90048, USA
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 S San Vicente Boulevard, A6600, Los Angeles, CA 90048, USA.
| |
Collapse
|
30
|
Téblick A, Peeters B, Langouche L, Van den Berghe G. Adrenal function and dysfunction in critically ill patients. Nat Rev Endocrinol 2019; 15:417-427. [PMID: 30850749 DOI: 10.1038/s41574-019-0185-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Critical illnesses are characterized by increased systemic cortisol availability, which is a vital part of the stress response. Relative adrenal failure (later termed critical-illness-related corticosteroid insufficiency (CIRCI)) is a condition in which the systemic availability of cortisol is assumed to be insufficiently high to face the stress of the illness and is most typically thought to occur in the acute phase of septic shock. Researchers suggested that CIRCI could be diagnosed by a suppressed incremental cortisol response to an injection of adrenocorticotropic hormone, irrespective of the baseline plasma cortisol. This concept triggered several randomized clinical trials on the impact of large stress doses of hydrocortisone to treat CIRCI, which gave conflicting results. Recent novel insights into the response of the hypothalamic-pituitary-adrenal axis to acute and prolonged critical illnesses challenge the concept of CIRCI, as currently defined, as well as the current practice guidelines for diagnosis and treatment. In this Review, these novel insights are integrated within a novel conceptual framework that can be used to re-appreciate adrenocortical function and dysfunction in the context of critical illness. This framework opens new avenues for further research and for preventive and/or therapeutic innovations.
Collapse
Affiliation(s)
- Arno Téblick
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Bram Peeters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium.
| |
Collapse
|
31
|
Pecoraro NC, Heiferman DM, Martin B, Li D, Johans SJ, Patel CR, Germanwala AV. Lower-dose perioperative steroid protocol during endoscopic endonasal pituitary adenoma resection. Surg Neurol Int 2019; 10:52. [PMID: 31528390 PMCID: PMC6743680 DOI: 10.25259/sni-68-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/30/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Perioperative steroid management for pituitary adenoma resections is multifaceted due to possible hypothalamic–pituitary–adrenal (HPA) axis disruption. Although many different strategies have been proposed, there is no standard protocol for prophylaxis of potential hypocortisolemia. Methods: We performed a retrospective analysis of consecutive endoscopic endonasal pituitary adenoma resections. Before March 2016, patients received ≥100 mg of hydrocortisone intraoperatively followed by 2 mg of dexamethasone immediately postoperatively in most of the patients. Subsequently, patients received only 50 mg of hydrocortisone intraoperatively. A morning cortisol level was checked on postoperative day (POD) 2, and if it was <10 mcg/dL, patients remained on maintenance hydrocortisone. At 6 weeks, serum cortisol was redrawn and low-dose therapy was weaned when indicated. Results: Of those who received ≥100 mg of hydrocortisone, 8 of 24 (33.3%) were discharged on hydrocortisone compared to 1 of 14 (7.1%) who received 50 mg. 18 of 24 (75%) of ≥100 mg group received dexamethasone on POD 1, and of those, 8 (44.4%) were discharged on hydrocortisone. Of those who received ≥100 mg and were on outpatient steroid therapy initially, 3 of 8 (37.5%) required continuation after 6 weeks compared to none who received 50 mg. There was an association between patient’s intraoperative/immediate postoperative steroid use and steroid continuation at discharge. Conclusion: Through our experience, we hypothesize that ≥100 mg of hydrocortisone intraoperatively followed by postoperative dexamethasone may be overly suppressive in patients with otherwise normally functioning HPA. A 50 mg intraoperative dose alone may be considered to lower rates of unnecessary steroid regimens postoperatively.
Collapse
Affiliation(s)
- Nathan C Pecoraro
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Daniel M Heiferman
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Brendan Martin
- Department of Clinical Research Office Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Daphne Li
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Stephen J Johans
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Chirag R Patel
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| | - Anand V Germanwala
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois.,Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois.,Department of Surgery, Edward Hines, Jr. VA Medical Center, Hines, Illinois, USA
| |
Collapse
|
32
|
Chouairi F, Torabi SJ, Mercier MR, Gabrick KS, Alperovich M. Chronic steroid use as an independent risk factor for perioperative complications. Surgery 2019; 165:990-995. [PMID: 30765140 DOI: 10.1016/j.surg.2018.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 12/19/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Corticosteroid use continues to rise nationally. Studies have evaluated the impact of chronic steroid use on surgical outcomes in smaller populations. This study investigated the impact of chronic steroid use on perioperative surgical outcomes in a surgical cohort of more than 5 million surgical patients, using a statistically rigorous methodology. METHODS The National Surgical Quality Improvement Program Database was queried 2008-2016 to evaluate chronic steroid use. Patient demographics, comorbidities, and outcomes were compared, using χ2 and t test analysis, and then repeated after propensity score matching. Finally, a double-adjustment logistic regression was utilized, yielding odds ratios to assess the effect of chronic steroids on perioperative outcomes within the matched population. RESULTS Between 2008 and 2016, a total of 5,244,588 patients met inclusion criteria, of whom 181,901 (3.5%) were taking steroids for a minimum of 30 days before surgery. Patients on chronic steroids had significantly more comorbidities compared with the remaining population. After propensity score matching and double-adjusted logistic regression, chronic steroid use was found to be associated with increased surgical complications and poorer surgical outcomes. Chronic steroid use significantly increased a patient's risk of having a hospital stay longer than 30 days by 19%, risk of readmission within 30 days by 58%, risk of reoperation by 21%, and risk of death by 32%. CONCLUSION After controlling for differences in comorbidities and demographics, patients on chronic steroids have significantly poorer perioperative outcomes. Chronic steroid use should be evaluated and, if possible, addressed before surgery, given their significant impact on surgical outcomes.
Collapse
Affiliation(s)
- Fouad Chouairi
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Sina J Torabi
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Michael R Mercier
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Kyle S Gabrick
- Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Michael Alperovich
- Department of Surgery, Yale University School of Medicine, New Haven, CT.
| |
Collapse
|
33
|
Ahmet A, Mokashi A, Goldbloom EB, Huot C, Jurencak R, Krishnamoorthy P, Rowan-Legg A, Kim H, Pancer L, Kovesi T. Adrenal suppression from glucocorticoids: preventing an iatrogenic cause of morbidity and mortality in children. BMJ Paediatr Open 2019; 3:e000569. [PMID: 31750407 PMCID: PMC6830460 DOI: 10.1136/bmjpo-2019-000569] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/26/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022] Open
Abstract
Adrenal suppression (AS) is an important side effect of glucocorticoids (GCs) including inhaled corticosteroids (ICS). AS can often be asymptomatic or associated with non-specific symptoms until a physiological stress such as an illness precipitates an adrenal crisis. Morbidity and death associated with adrenal crisis is preventable but continues to be reported in children. There is a lack of consensus about the management of children at risk of AS. However, healthcare professionals need to develop an awareness and approach to keep these children safe. In this article, current knowledge of the risk factors, diagnosis and management of AS are reviewed while drawing attention to knowledge gaps and areas of controversy. Possible strategies to reduce the morbidity associated with this iatrogenic condition are provided for healthcare professionals.
Collapse
Affiliation(s)
- Alexandra Ahmet
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Arati Mokashi
- Pediatrics, Division of Endocrinology, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ellen B Goldbloom
- Pediatrics, Division of Endocrinology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Celine Huot
- Pediatrics, Division of Endocrinology, University of Montreal, Montreal, Quebec, Canada.,Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Roman Jurencak
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Rheumatology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Preetha Krishnamoorthy
- Pediatrics, Division of Endocrinology, Montreal Childrens Hospital, Montreal, Quebec, Canada.,Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Anne Rowan-Legg
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Division of Clinical Immunology and Allergy, St. Joseph's Hospital, London, Ontario, Canada
| | - Larry Pancer
- Pediatrics, Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Tom Kovesi
- Pediatrics, University of Ottawa, Ottawa, Ontario, Canada.,Pediatrics, Division of Respirology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| |
Collapse
|
34
|
Chilkoti GT, Singh A, Mohta M, Saxena AK. Perioperative "stress dose" of corticosteroid: Pharmacological and clinical perspective. J Anaesthesiol Clin Pharmacol 2019; 35:147-152. [PMID: 31303699 PMCID: PMC6598572 DOI: 10.4103/joacp.joacp_242_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Geetanjali T Chilkoti
- Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
| | - Anshul Singh
- Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
| | - Medha Mohta
- Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
| | - Ashok Kumar Saxena
- Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi, India
| |
Collapse
|
35
|
Farag AM. Head and Neck Manifestations of Endocrine Disorders. Atlas Oral Maxillofac Surg Clin North Am 2018; 25:197-207. [PMID: 28778308 DOI: 10.1016/j.cxom.2017.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Arwa M Farag
- Division of Oral Medicine, Department of Diagnostic Sciences, Tufts University School of Dental Medicine, 1 Kneeland Street, DHS #638, Boston, MA 02111, USA; Department of Oral Medicine, Faculty of Dentistry, King AbdulAziz University, 1 Umm Al Muminin Road, Jeddah 21589, Kingdom of Saudi Arabia.
| |
Collapse
|
36
|
Corticosteroids administration to improve outcome in high-risk surgical patients. Curr Opin Crit Care 2018; 24:575-580. [DOI: 10.1097/mcc.0000000000000553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
37
|
Maria K, Evangelos KA, Dimitris KP, Maria K, Ioannis K, Margarita G. Postoperative stress and pain response applying fast-track protocol in patients undergoing hepatectomy. J Perioper Pract 2018; 29:368-377. [PMID: 30417764 DOI: 10.1177/1750458918812293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aim To assess the clinical parameters and compare the stress and pain response between fast-track recovery protocol and conventional treatment in patients undergoing major liver resection. Methods Eighty-eight patients suffering from malignant liver tumours were surgically treated from May 2012 to March 2015. After randomisation, they were prospectively divided into two groups: group fast-track patients (n = 46) and group conventional treatment patients (n = 42). Demographic and clinical data were collected and patients were assessed with pain scale (behavioural observation scale and visual analog scale), while depression levels were evaluated with Zung self-rating depression scale and three Numeric Analog Scale self-reported questions. Peripheral blood samples were collected at time points: T1 on the admission day, T2 on the day of surgery and T3 on the day of discharge examining serum levels of adrenocorticotropic hormone and cortisol. Conclusion Fast-track recovery protocols seem to be associated with improvement in several clinical parameters, without compromising, biologic or emotional stress in patients undergoing major liver resection.
Collapse
Affiliation(s)
- Kapritsou Maria
- Chief Nurse of PACU, Hellenic Anticancer Hospital "Saint Savvas", Day Care Surgery "N. KOURKOULOS" Hellenic Anticancer Institute, "Saint Savvas" Hospital, Athens, Greece
| | | | | | - Kalafati Maria
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | - Kaklamanos Ioannis
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | | |
Collapse
|
38
|
|
39
|
Rushworth RL, Torpy DJ, Stratakis CA, Falhammar H. Adrenal Crises in Children: Perspectives and Research Directions. Horm Res Paediatr 2018; 89:341-351. [PMID: 29874655 DOI: 10.1159/000481660] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
Adrenal crises (AC) are life-threatening physiological disturbances that occur at a rate of 5-10/100 patient years in patients with adrenal insufficiency (AI). Despite their seriousness, there is a paucity of information on the epidemiology of AC events in the paediatric population specifically, as most investigations have focused on AI and ACs in adults. Improved surveillance of AC-related morbidity and mortality should improve the delineation of AC risk overall and among different subgroups of paediatric patients with AI. Valid incidence measures are essential for this purpose and also for the evaluation of interventions aimed at reducing adverse health outcomes from ACs. However, the absence of an agreed AC definition limits the potential benefit of research and surveillance in this area. While approaches to the treatment and prevention of ACs have much in common across the lifespan, there are important differences between children and adults with regards to the physiological, psychological, and social milieu in which these events occur. Education is considered to be an essential element of AC prevention but studies have shown that ACs occur even among well-educated patients, suggesting that new strategies may be needed. In this review, we examine the current knowledge regarding AC events in children with AI; assess the existing definitions of an AC and offer a new definition for use in research and the clinic; and suggest areas for further investigation that are aimed at reducing the incidence and health impact of ACs in the paediatric age group.
Collapse
Affiliation(s)
- R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, New South Wales, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital and University of Adelaide, Adelaide, South Australia, Australia
| | - Constantine A Stratakis
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Menzies School of Health Research and Royal Darwin Hospital, Tiwi, Northwest Territories, Australia
| |
Collapse
|
40
|
Perioperative Glucocorticoid Treatment of Soft Tissue Reconstruction in Patients on Long-term Steroid Therapy: The Experience of 6 Cases Using Reversed Posterior Interosseous Flap for Hand Neoplasm Surgery. Ann Plast Surg 2018; 81:302-304. [PMID: 29905611 PMCID: PMC6143215 DOI: 10.1097/sap.0000000000001534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Introduction Long-term steroid therapy is associated with increased postoperative morbidity. Whether to use a stress dose of glucocorticoids (GCs) in surgical patients remains controversial. In the present study, we reported our experience in perioperative GC treatment of 6 patients on long-term steroid therapy for autoimmune diseases undergoing hand reconstruction using reversed interosseous flap. Methods The reversed interosseous flap reconstructions were performed after local extended resection of hand neoplasms. The patients were all diagnosed with autoimmune diseases and were undergoing long-term steroid therapy. Stress dose of GCs was not given in any case, and all the patients either remained on their baseline maintenance dose or decreased the dose until the morning of the operation day. Hypotension, water-electrolyte imbalance, hypoglycemia, and other symptoms of adrenal insufficiency were carefully assessed. Appearances of flap complications were recorded. Results None of the patients developed hypotension or other symptomatic adrenal insufficiency. Flap infection, venous congestion, or complete or partial loss of flap was not observed in any patient. Effusion underneath the flap was developed in only 1 case and was solved by proper drainage. Conclusions It is safe, reliable, and versatile to use reversed interosseous flap to repair hand defects in patients on long-term steroid therapy. A stress dose of GCs might not be necessary in this procedure and other equally moderate soft tissue reconstructive surgeries.
Collapse
|
41
|
Groleau C, Morin SN, Vautour L, Amar-Zifkin A, Bessissow A. Perioperative corticosteroid administration: a systematic review and descriptive analysis. Perioper Med (Lond) 2018; 7:10. [PMID: 29977522 PMCID: PMC5994041 DOI: 10.1186/s13741-018-0092-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/21/2018] [Indexed: 01/20/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- C Groleau
- 1Hematology Residency Program, McGill University, Montreal, Canada
| | - S N Morin
- 2Department of Medicine, Division of General Internal Medicine, McGill University Health Centre, Montreal, Canada
| | - L Vautour
- 3Department of Medicine, Division of Endocrinology, McGill University Health Centre, Montreal, Canada
| | - A Amar-Zifkin
- 4Medical library, McGill University Health Centre, Montreal, Canada
| | - A Bessissow
- 2Department of Medicine, Division of General Internal Medicine, McGill University Health Centre, Montreal, Canada
| |
Collapse
|
42
|
Gualtierotti R, Parisi M, Ingegnoli F. Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview. Adv Ther 2018; 35:439-456. [PMID: 29556907 PMCID: PMC5910481 DOI: 10.1007/s12325-018-0686-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.
Collapse
|
43
|
Rheumatoid Arthritis, Disease Modifying Agents, and Periprosthetic Joint Infection: What Does a Joint Surgeon Need to Know? J Arthroplasty 2018; 33:1258-1264. [PMID: 29325724 DOI: 10.1016/j.arth.2017.11.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/22/2017] [Accepted: 11/15/2017] [Indexed: 02/01/2023] Open
Abstract
The incidence of periprosthetic joint infection (PJI) among patients with rheumatoid arthritis (RA) is 1.6× greater than in patients undergoing the same procedure for osteoarthritis. This higher risk "may" be due to the immunosuppressive therapies for RA patients including corticosteroids, such as prednisone, and disease-modifying antirheumatic drugs (DMARDs), such as methotrexate. There is a debate about the role of DMARDs in increasing the incidence of subsequent PJI. Studies show conflicting results, with some demonstrating no significant increase in the rates of PJI and some finding otherwise. The International Consensus Meeting on PJI recommended that DMARDs should be halted prior to an elective total joint arthroplasty based on their half-life. Moreover, the International Consensus Meeting stated that cessation of immunosuppressant medications should be performed in consultation with and under the direction of the treating physician. In this review, we aimed to provide an introduction to the available treatment options and cover the recommendations on the treatment protocols for RA patients who undergo elective total joint arthroplasty.
Collapse
|
44
|
Cortet C, Barat P, Zenaty D, Guignat L, Chanson P. Group 5: Acute adrenal insufficiency in adults and pediatric patients. ANNALES D'ENDOCRINOLOGIE 2017; 78:535-543. [DOI: 10.1016/j.ando.2017.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
45
|
Abstract
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.
Collapse
|
46
|
Franco AS, Iuamoto LR, Pereira RMR. Perioperative management of drugs commonly used in patients with rheumatic diseases: a review. Clinics (Sao Paulo) 2017; 72:386-390. [PMID: 28658439 PMCID: PMC5463249 DOI: 10.6061/clinics/2017(06)09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/24/2017] [Indexed: 01/20/2023] Open
Abstract
Rheumatic diseases are very prevalent, affecting about 7 million people in North America; they affect the musculoskeletal system, often with systemic involvement and potential for serious consequences and limitation on quality of life. Clinical treatment is usually long-term and includes drugs that are considered either simple or complex and are occasionally unknown to many health professionals who do not know how to manage these patients in emergency units and surgical wards. Thus, it is important for clinicians, surgeons and anesthesiologists who are involved with rheumatic patients undergoing surgery to know the basic principles of therapy and perioperative management. This study aims to do a review of the perioperative management of the most commonly used drugs in rheumatologic patients. Manuscripts used in this review were identified by surveying MEDLINE, LILACS, EMBASE, and COCHRANE databases and included studies containing i) the perioperative management of commonly used drugs in patients with rheumatic diseases: and ii) rheumatic diseases. They are didactically discussed according to the mechanism of action and pharmacokinetics; and perioperative management. In total, 259 articles related to the topic were identified. Every medical professional should be aware of the types of drugs that are appropriate for continuous use and should know the various effects of these drugs before indicating surgery or assisting a rheumatic patient postoperatively. This information could prevent possible complications that could affect a wide range of patients.
Collapse
Affiliation(s)
- André Silva Franco
- Rheumatology Division, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, BR
| | - Leandro Ryuchi Iuamoto
- Rheumatology Division, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, BR
| | - Rosa Maria Rodrigues Pereira
- Rheumatology Division, Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, BR
- *Corresponding author. E-mail:
| |
Collapse
|
47
|
Jurgens PT, Aquilante CL, Page RL, Ambardekar AV. Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care. Semin Cardiothorac Vasc Anesth 2017; 21:235-244. [PMID: 28466755 DOI: 10.1177/1089253217706164] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.
Collapse
Affiliation(s)
- Paul T Jurgens
- 1 School of Medicine, Department of Medicine, University of Colorado, Aurora Colorado, CO, USA
| | - Christina L Aquilante
- 2 Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Pharmaceutical Sciences, University of Colorado, Aurora Colorado, CO, USA
| | - Robert L Page
- 3 Skaggs School of Pharmacy and Pharmaceutical Sciences, Department of Clinical Pharmacy, University of Colorado, Aurora Colorado, CO, USA
| | - Amrut V Ambardekar
- 4 School of Medicine, Division of Cardiology, University of Colorado, Aurora Colorado, CO, USA
| |
Collapse
|
48
|
Owa T, Mimura K, Kakigano A, Matsuzaki S, Kumasawa K, Endo M, Tomimatsu T, Kimura T. Pregnancy outcomes in women with different doses of corticosteroid supplementation during labor and delivery. J Obstet Gynaecol Res 2017; 43:1132-1138. [DOI: 10.1111/jog.13336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/12/2017] [Accepted: 02/26/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Takao Owa
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Kazuya Mimura
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Aiko Kakigano
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Shinya Matsuzaki
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Masayuki Endo
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Takuji Tomimatsu
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology; Osaka University Graduate School of Medicine; Osaka Japan
| |
Collapse
|
49
|
Lightner AL, Shen B. Perioperative use of immunosuppressive medications in patients with Crohn's disease in the new "biological era". Gastroenterol Rep (Oxf) 2017; 5:165-177. [PMID: 28852521 PMCID: PMC5554387 DOI: 10.1093/gastro/gow046] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Amy L Lightner
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota, MN, USA
| | - Bo Shen
- Center for Inflammatory Bowel Diseases, Digestive Disease and Surgery Institute, the Cleveland Clinic Foundation, Cleveland, OH, USA
| |
Collapse
|
50
|
Prete A, Corsello SM, Salvatori R. Current best practice in the management of patients after pituitary surgery. Ther Adv Endocrinol Metab 2017; 8:33-48. [PMID: 28377801 PMCID: PMC5363454 DOI: 10.1177/2042018816687240] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 12/12/2016] [Indexed: 12/25/2022] Open
Abstract
Sellar and parasellar masses are a common finding, and most of them are treated surgically via transsphenoidal approach. This type of surgery has revolutionized the approach to several hypothalamic-pituitary diseases and is usually effective, and well-tolerated by the patient. However, given the complex anatomy and high density of glandular, neurological and vascular structures in a confined space, transsphenoidal surgery harbors a substantial risk of complications. Hypopituitarism is one of the most frequent sequelae, with central adrenal insufficiency being the deficit that requires a timely diagnosis and treatment. The perioperative management of AI is influenced by the preoperative status of the hypothalamic-pituitary-adrenal axis. Disorders of water metabolism are another common complication, and they can span from diabetes insipidus, to the syndrome of inappropriate antidiuretic hormone secretion, up to the rare cerebral salt-wasting syndrome. These abnormalities are often transient, but require careful monitoring and management in order to avoid abrupt variations of blood sodium levels. Cerebrospinal fluid leaks, damage to neurological structures such as the optic chiasm, and vascular complications can worsen the postoperative course after transsphenoidal surgery as well. Finally, long-term follow up after surgery varies depending on the underlying pathology, and is most challenging in patients with acromegaly and Cushing disease, in whom failure of primary pituitary surgery is a major concern. When these pituitary functioning adenomas persist or relapse after neurosurgery other treatment options are considered, including repeated surgery, radiotherapy, and medical therapy.
Collapse
Affiliation(s)
- Alessandro Prete
- Unit of Endocrinology, Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
| | - Salvatore Maria Corsello
- Unit of Endocrinology, Facoltà di Medicina e Chirurgia, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, Rome, Italy
| | | |
Collapse
|