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Barker OJH, Ramesh AV, Kangesan I, Barnes J, Harrogate S, Gupta S, Reeves BC, Gibbison B. Peri-operative Replacement of Exogenous Steroids (PREdS): a national audit of current peri-operative prescribing for patients taking therapeutic steroids. Anaesthesia 2024. [PMID: 39096191 DOI: 10.1111/anae.16388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Approximately 1% of the UK population take oral corticosteroids for ≥ 28 days each year, for broadly two reasons: deficiency in corticosteroid requiring replacement; or therapeutic corticosteroid for inflammatory conditions. Acute deficiency can occur at times of physiological stress (e.g. surgery), potentially leading to major complications. The Association of Anaesthetists' 2020 consensus guideline provides detailed advice for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency. This national audit aimed to assess compliance with this guideline. METHODS Data were collected from 59 Trusts over 14 consecutive days for all eligible patients undergoing procedures under the care of an anaesthetist. Patients who were prescribed ≥ 5 mg oral prednisolone equivalents pre-operatively, in whom supplementary corticosteroid would be indicated, were compared with those prescribed < 5 mg oral prednisolone equivalents. RESULTS Operations for 21,731 patients were audited: 277 (1.3%) patients were taking therapeutic corticosteroids. Detailed peri-operative data were collected for all patients receiving therapeutic corticosteroids: 201/277 (73%) were ASA physical status ≥ 3; 184/277 (66%) underwent elective procedures; and 252/277 (91%) were prescribed prednisolone pre-operatively, of whom 219/277 (79%) were prescribed ≥ 5 mg oral prednisolone equivalents. In the patients who were prescribed ≥ 5 mg oral prednisolone equivalents, 186/219 (85%) received pre-operative glucocorticoid supplementation and 97/219 (42%) received it postoperatively; however, only 67/219 (31%) and 43/219 (20%) respectively received glucocorticoid supplementation according to the guidelines. Overall, peri-operative prescribing was compliant in 19/219 (9%) patients. A similar proportion, 30/219 (14%), received no supplementation. In the patients taking < 5 mg oral prednisolone equivalents pre-operatively, 28/58 (48%) received inappropriate supplementation. CONCLUSIONS Despite 125/277 (45%) of anaesthetists reporting Association of Anaesthetists' guidelines use, compliance remained low, with adherence in only 27/125 (22%) patients. Further research is required to identify the correct peri-operative strategy for patients taking therapeutic corticosteroids.
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Affiliation(s)
- Oliver J H Barker
- Department of Anaesthesia, University Hospitals Bristol and Weston, Bristol, UK
| | - Aravind V Ramesh
- Department of Health Sciences, University of Bristol, Bristol, UK
| | - Inthu Kangesan
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathan Barnes
- Department of Anaesthesia, University Hospitals Bristol and Weston, Bristol, UK
| | | | - Swati Gupta
- Department of Anaesthesia, University Hospitals Bristol and Weston, Bristol, UK
| | | | - Ben Gibbison
- Department of Anaesthesia, University Hospitals Bristol and Weston, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
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Goder N, Gerstenhaber F, Gal Oz A, Stavi D, Angel Y, Nini A, Lichter Y, Sold O. Cortisol Levels During First Admission Day Are Associated With Clinical Outcomes in Surgical Critically Ill Patients. Crit Care Explor 2024; 6:e1086. [PMID: 38722303 PMCID: PMC11081545 DOI: 10.1097/cce.0000000000001086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
IMPORTANCE To explore the correlation between cortisol levels during first admission day and clinical outcomes. OBJECTIVES Although most patients exhibit a surge in cortisol levels in response to stress, some suffer from critical illness-related corticosteroid insufficiency (CIRCI). Literature remains inconclusive as to which of these patients are at greater risk of poor outcomes. DESIGN A retrospective study. SETTING A surgical ICU (SICU) in a tertiary medical center. PARTICIPANTS Critically ill patients admitted to the SICU who were not treated with steroids. MAIN OUTCOMES AND MEASURES Levels of cortisol taken within 24 hours of admission (day 1 [D1] cortisol) in 1412 eligible patients were collected and analyzed. Results were categorized into four groups: low (0-10 µg/dL), normal (10-25 µg/dL), high (25-50 µg/dL), and very high (above 50 µg/dL) cortisol levels. Primary endpoint was 90-day mortality. Secondary endpoints were the need for organ support (use of vasopressors and mechanical ventilation [MV]), ICU length of stay (LOS), and duration of MV. RESULTS The majority of patients (63%) had high or very high D1 cortisol levels, whereas 7.6% had low levels and thus could be diagnosed with CIRCI. There were statistically significant differences in 90-day mortality between the four groups and very high levels were found to be an independent risk factor for mortality, primarily in patients with Sequential Organ Failure Assessment (SOFA) less than or equal to 3 or SOFA greater than or equal to 7. Higher cortisol levels were associated with all secondary endpoints. CIRCI was associated with favorable outcomes. CONCLUSIONS AND RELEVANCE In critically ill surgical patients D1 cortisol levels above 50 mcg/dL were associated with mortality, need for organ support, longer ICU LOS, and duration of MV, whereas low levels correlated with good clinical outcomes even though untreated. D1 cortisol level greater than 50 mcg/dL can help discriminate nonsurvivors from survivors when SOFA less than or equal to 3 or SOFA greater than or equal to 7.
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Affiliation(s)
- Noam Goder
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fabian Gerstenhaber
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Gal Oz
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dekel Stavi
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoel Angel
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Asaph Nini
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lichter
- Division of Anesthesia, Pain Management and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oded Sold
- Division of Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hahn C, Budhram A, Alikhani K, AlOhaly N, Beecher G, Blevins G, Brooks J, Carruthers R, Comtois J, Cowan J, de Robles P, Hébert J, Kapadia RK, Lapointe S, Mackie A, Mason W, McLane B, Muccilli A, Poliakov I, Smyth P, Williams KG, Uy C, McCombe JA. Canadian Consensus Guidelines for the Diagnosis and Treatment of Autoimmune Encephalitis in Adults. Can J Neurol Sci 2024:1-21. [PMID: 38312020 DOI: 10.1017/cjn.2024.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024]
Abstract
Autoimmune encephalitis is increasingly recognized as a neurologic cause of acute mental status changes with similar prevalence to infectious encephalitis. Despite rising awareness, approaches to diagnosis remain inconsistent and evidence for optimal treatment is limited. The following Canadian guidelines represent a consensus and evidence (where available) based approach to both the diagnosis and treatment of adult patients with autoimmune encephalitis. The guidelines were developed using a modified RAND process and included input from specialists in autoimmune neurology, neuropsychiatry and infectious diseases. These guidelines are targeted at front line clinicians and were created to provide a pragmatic and practical approach to managing such patients in the acute setting.
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Affiliation(s)
- Christopher Hahn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Adrian Budhram
- Clinical Neurological Sciences, London Health Sciences Centre, London, ON, Canada
- Department of Pathology and Laboratory Medicine, Western University, London Health Sciences Centre, London, ON, Canada
| | - Katayoun Alikhani
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nasser AlOhaly
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Grayson Beecher
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - Gregg Blevins
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | - John Brooks
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Robert Carruthers
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
| | - Jacynthe Comtois
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Juthaporn Cowan
- Division of Infectious Diseases, Department of Medicine Ottawa Hospital, Ottawa, ON, Canada
| | - Paula de Robles
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, University of Calgary, Calgary, AB, Canada
| | - Julien Hébert
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Ronak K Kapadia
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Sarah Lapointe
- Neurosciences, Universite de Montreal Faculte de Medecine, Montreal, QC, Canada
| | - Aaron Mackie
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Warren Mason
- Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Brienne McLane
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | | | - Ilia Poliakov
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada
| | - Penelope Smyth
- Division of Neurology, University of Alberta, Edmonton, AB, Canada
| | | | - Christopher Uy
- Division of Neurology, University of British Columbia, Vancouver, BC, Canada
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Pestana I, Guimarães H, Saraiva A, Veiga D, Machado H. Adrenal Crisis During Cesarean Section in a Patient With Primary Adrenal Insufficiency. Cureus 2023; 15:e49964. [PMID: 38179347 PMCID: PMC10765761 DOI: 10.7759/cureus.49964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a type of primary adrenal insufficiency (AI) that predisposes to adrenal crisis (AC) during stress. We describe a case of a primipara with CAH who was admitted in labor. To prevent AC, glucocorticoid replacement was given according to guidelines. Due to fetal decelerations, an emergency C-section was performed under general anesthesia following which refractory hypotension emerged. The diagnosis of AC was considered, and hydrocortisone was given with sustained hemodynamic improvement. AC is a life-threatening emergency whose diagnosis requires a high index of suspicion. Despite adequate steroid coverage, additional stressors may precipitate AC, so it is of paramount importance that anesthesiologists consider this emergency.
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Affiliation(s)
- Inês Pestana
- Anesthesiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Henrique Guimarães
- Anesthesiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Alexandra Saraiva
- Anesthesiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Dalila Veiga
- Anesthesiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
| | - Humberto Machado
- Anesthesiology, Centro Hospitalar Universitário de Santo António, Porto, PRT
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Kumari K, Rathod D, Meshram T, Mohammed S, Raju S, Sharma A, Chaudhary B, Bhatia P. Perioperative anesthesia challenges and outcomes of patients with Rhino-Orbito-Cerebral Mucormycosis during the second wave of COVID-19 pandemic: An observational study. J Anaesthesiol Clin Pharmacol 2023; 39:615-621. [PMID: 38269163 PMCID: PMC10805186 DOI: 10.4103/joacp.joacp_169_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 01/26/2024] Open
Abstract
Background and Aims A rapid surge in rhino-orbito-cerebral mucormycosis (ROCM) cases was reported during the second wave of COVID, especially in India, needing extensive surgical debridement along with medical management. The present study was planned to observe perioperative anesthesia challenges and outcomes of patients with ROCM during the second wave of the COVID-19 pandemic. The primary objective was to observe intraoperative anesthesia challenges and the secondary objectives were to observe postoperative challenges and outcomes of patients. Material and Methods This was a single-centered, bidirectional (retrospective and prospective) observational study, conducted at a tertiary care center. We enrolled 218 adult patients scheduled for surgical debridement of ROCM under general anesthesia. Demographics, COVID status, comorbid illness, intraoperative challenges (difficult airway, hemodynamic instability, blood loss), and postoperative outcome (postoperative mechanical ventilation, and mortality rate) were noted. Results The majority of the patients were males (71%) and had diabetes mellitus (54%). COVID-associated mucormycosis was seen in 67% and 41% of them received steroids. Post-induction hypotension was noted in 20.6% of patients, and 14.2% had intraoperative hypotension out of which 5.5% required vasopressor support. Difficult mask ventilation and difficult intubation were reported in 7.3% and 6.4% of patients, respectively. No significant difference was found among intraoperative challenges when COVID mucormycosis was compared to non-COVID mucormycosis. Postoperative mechanical ventilation and ICU care were required in 41.3%, whereas mortality was seen in 11.5% of patients. The mortality was significantly more (P = 0.041) in patients with COVID mucormycosis (13%) compared to that with non-COVID mucormycosis (4.2%). Conclusion Diabetic male patients who received steroids during COVID illness are at the highest risk of developing ROCM. Difficult airway and hemodynamic instability, are significant perioperative challenges encountered by anesthesiologists. Postoperative ICU management is crucial for decreasing postoperative morbidity and mortality.
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Affiliation(s)
- Kamlesh Kumari
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Darshana Rathod
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Tanvi Meshram
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sadik Mohammed
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sachith Raju
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Ankur Sharma
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Bikram Chaudhary
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pradeep Bhatia
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Jiang XY, Gong MQ, Zhang HJ, Peng AQ, Xie Z, Sun D, Liu L, Zhou SQ, Chen H, Yang XF, Song JF, Yu B, Jiang Q, Ma X, Gu J, Yang F, Zeng H, Zou QM. The safety and immunogenicity of a recombinant five-antigen Staphylococcus aureus vaccine among patients undergoing elective surgery for closed fractures: A randomized, double-blind, placebo-controlled, multicenter phase 2 clinical trial. Vaccine 2023; 41:5562-5571. [PMID: 37516573 DOI: 10.1016/j.vaccine.2023.07.047] [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: 02/14/2023] [Revised: 06/22/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Vaccines are urgently required to control Staphylococcus aureus hospital and community infections and reduce the use of antibiotics. Here, we report the safety and immunogenicity of a recombinant five-antigen Staphylococcus aureus vaccine (rFSAV) in patients undergoing elective surgery for closed fractures. METHODS A randomized, double-blind, placebo-controlled, multicenter phase 2 clinical trial was carried out in 10 clinical research centers in China. Patients undergoing elective surgery for closed fractures, aged 18-70 years, were randomly allocated at a ratio of 1:1 to receive the rFSAV or placebo at a regimen of two doses on day 0 and another dose on day 7. All participants and investigators remained blinded during the study period. The safety endpoint was the incidence of adverse events within 180 days. The immunogenicity endpoints included the level of specific antibodies to five antigens after vaccination, as well as opsonophagocytic antibodies. RESULTS A total of 348 eligible participants were randomized to the rFSAV (n = 174) and placebo (n = 174) groups. No grade 3 local adverse events occurred. There was no significant difference in the incidence of overall systemic adverse events between the experimental (40.24 %) and control groups (33.72 %) within 180 days after the first immunization. The antigen-specific binding antibodies started to increase at days 7 and reached their peaks at 10-14 days after the first immunization. The rapid and potent opsonophagocytic antibodies were also substantially above the background levels. CONCLUSIONS rFSAV is safe and well-tolerated in patients undergoing elective surgery for closed fractures. It elicited rapid and robust specific humoral immune responses using the perioperative immunization procedure. These results provide evidence for further clinical trials to confirm the vaccine efficacy. China's Drug Clinical Trials Registration and Information Publicity Platform registration number: CTR20181788. WHO International Clinical Trial Registry Platform identifier: ChiCTR2200066259.
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Affiliation(s)
- Xie-Yuan Jiang
- Department of Trauma and Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Mao-Qi Gong
- Department of Trauma and Orthopedics, Beijing Jishuitan Hospital, Beijing, China
| | - Hua-Jie Zhang
- DTaP and Toxins Division, National Institutes for Food and Drug Control, Key Laboratory of the Ministry of Health for Research on Quality and Standardization of Biotech Products, Beijing, China
| | - A-Qin Peng
- Trauma Emergency Center of Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Zhao Xie
- Orthopedic Department of Southwest Hospital, Army Medical University, Chongqing, China
| | - Dong Sun
- Orthopedic Department of Southwest Hospital, Army Medical University, Chongqing, China
| | - Lie Liu
- Orthopedic Department of the Eighth Affiliated Hospital, Sun Yat-sen University, Zhongshan, Guangdong, China; Orthopedic Department of West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shuang-Quan Zhou
- Chinese Osteo-traumatology Department of Shenyang Orthopedic Hospital, Shenyang, Liaoning, China
| | - Hua Chen
- Department of Trauma and Orthopedics of the 2nd School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xiao-Fei Yang
- Orthopedic Department of Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Jie-Fu Song
- Orthopedic Department of Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Bin Yu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China; Guangdong Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China; Branch of National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Nanjing, Jiangsu, China
| | - Xiao Ma
- DTaP and Toxins Division, National Institutes for Food and Drug Control, Key Laboratory of the Ministry of Health for Research on Quality and Standardization of Biotech Products, Beijing, China
| | - Jiang Gu
- National Engineering Research Center of Immunological, Department of Microbiology and Biochemical Pharmacy, College of Pharmacy and Laboratory Medicine, Army Medical University, Chongqing, China
| | - Feng Yang
- Chengdu Olymvax Biopharmaceuticals Inc., Chengdu, Sichuan, China.
| | - Hao Zeng
- National Engineering Research Center of Immunological, Department of Microbiology and Biochemical Pharmacy, College of Pharmacy and Laboratory Medicine, Army Medical University, Chongqing, China; State Key Laboratory of Trauma, Burn and Combined Injury, Army Medical University, Chongqing, China.
| | - Quan-Ming Zou
- National Engineering Research Center of Immunological, Department of Microbiology and Biochemical Pharmacy, College of Pharmacy and Laboratory Medicine, Army Medical University, Chongqing, China.
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Foster MA, Lunn MP, Carr AS. First-line immunosuppression in neuromuscular diseases. Pract Neurol 2023:pn-2023-003708. [PMID: 37173131 DOI: 10.1136/pn-2023-003708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
Autoimmune neuromuscular diseases are common and often treatable causes for peripheral nervous system dysfunction. If not optimally managed, they result in meaningful impairments and disability. The treating neurologist should aim to maximise clinical recovery with minimal iatrogenic risk. This requires careful patient and medication selection, appropriate counselling and close monitoring of clinical efficacy and safety. Here, we summarise our consensus departmental approach to first-line immunosuppression in neuromuscular diseases. We combine multispecialty evidence and expertise with a focus on autoimmune neuromuscular diseases to create guidance on starting, dosing and monitoring for toxic effects of the commonly used drugs. These include corticosteroids, steroid-sparing agents and cyclophosphamide. We also provide efficacy monitoring advice, as clinical response informs dosage and drug choice. The principles of this approach could be applied across much of the spectrum of immune-mediated neurological disorders where there is significant therapeutic crossover.
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Affiliation(s)
- Michael A Foster
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Division of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Michael Pt Lunn
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Aisling S Carr
- UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
- Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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8
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Is Preoperative Adrenal Insufficiency Screening Necessary for Cardiovascular Thoracic Surgery Patients? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010152. [PMID: 36676776 PMCID: PMC9864834 DOI: 10.3390/medicina59010152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/07/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
Background: The association between adrenal insufficiency (AI) and the treatment outcomes of cardiothoracic surgery patients has been little reported. The aims of this study were to investigate the incidence of AI and to compare the post-surgical outcomes of patients with perioperatively treated AI and patients with a normal adrenal response. Methods: A 1.5-year prospective study was conducted in 98 patients scheduled for cardiothoracic surgery. Patients were categorized as either AI or normal-adrenal-response patients. Those with AI were treated with stress doses of glucocorticoid perioperatively. The post-surgical outcomes of patients with AI and of those with a normal adrenaline response were analyzed using multivariable analysis. Results: The overall incidence of AI was 34.7%. There were no statistically significant differences in post-surgical outcomes, including prolonged hospital stay, postoperative infection, prolonged inotropic drug use and relative AI, between the two groups. Only the rate of hyperglycemia requiring insulin infusion was significantly higher in the AI group than in the non-AI group (OR = 14.15, 95% CI = 1.44-138.60, p = 0.02). Conclusions: The proper diagnosis and management of AI can result in surgical outcomes in AI patients comparable to those of normal-adrenal-response patients. Non-life-threatening hyperglycemia requiring insulin infusion was found only in the AI group.
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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.
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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.
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10
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Patel G, Kahlon S, Ganesh V. Patient on Multiple Hormone Replacement Therapy for Hip Arthroplasty: How to Omit Noise and Be Focused? Cureus 2022; 14:e27904. [PMID: 36120287 PMCID: PMC9467484 DOI: 10.7759/cureus.27904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/21/2022] Open
Abstract
Total hip arthroplasty (THA) surgery is usually performed in patients with trauma or old-aged osteoarthritis. There has been a recent increase in younger patients presenting with avascular necrosis (AVN) of the hip requiring replacement arthroplasty. Despite being from a younger age group, these patients may present with multiple comorbidities. We describe one such case of Cushing’s syndrome with AVN in a young patient with primary adrenal insufficiency, secondary hypothyroidism, and secondary hypogonadism on replacement therapy status post-transsphenoidal pituitary surgery and bilateral adrenalectomy, currently posted for total hip replacement (THR) surgery.
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11
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Russell LA, Craig C, Flores EK, Wainaina JN, Keshock M, Kasten MJ, Hepner DL, Edwards AF, Urman RD, Mauck KF, Oprea AD. Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc 2022; 97:1551-1571. [PMID: 35933139 DOI: 10.1016/j.mayocp.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/15/2022]
Abstract
Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.
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Affiliation(s)
- Linda A Russell
- Department of Rheumatology, Hospital for Special Surgery, New York, NY.
| | - Chad Craig
- Department of Medicine, Medical College of Wisconsin, Madison, NY
| | - Eva K Flores
- Section of Hospital Medicine, Department of Medicine, Weill Cornell Medical College, New York, NY
| | - J Njeri Wainaina
- Department of Medicine, Division of Infectious Diseases, Medical College of Wisconsin, Milwaukee, WI
| | - Maureen Keshock
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mary J Kasten
- Department of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - David L Hepner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Angela F Edwards
- Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Karen F Mauck
- Department of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Adriana D Oprea
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
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12
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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: 30] [Impact Index Per Article: 15.0] [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.
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13
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Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis. J Hand Surg Am 2022; 47:370-378. [PMID: 35184919 DOI: 10.1016/j.jhsa.2021.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/09/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.
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14
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Bayless DR, Caldarera TM, Harirah HM. Autoimmune polyglandular syndrome type 2 in pregnancy: a case report and review of the literature. CASE REPORTS IN PERINATAL MEDICINE 2022. [DOI: 10.1515/crpm-2020-0058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Objectives
Autoimmune polyglandular syndromes are uncommon heterogeneous conditions characterized by the association of two or more organ-specific endocrinopathies. Very few cases of these syndromes have been described during pregnancy. Here we report a case of autoimmune polyglandular syndrome type-2 presenting during pregnancy and complicated by preeclampsia with severe features.
Case presentation
The patient is a 35-year-old G7P0242 woman with a history of adrenal insufficiency, type 1 diabetes mellitus, and chronic lymphocytic thyroiditis. She was admitted to our institution at 34 weeks’ gestation for preterm contractions, nausea, and lower extremity edema for a few weeks prior to admission. At 35 weeks’ gestation, she developed preeclampsia with severe features requiring repeat cesarean section with good maternal and fetal outcomes. Recognizing the occurrence of this rare syndrome during pregnancy, adequate replacement of the deficient hormones, and close maternal and fetal surveillance are essential to achieving favorable outcomes.
Conclusions
To our knowledge, this is the first reported case of a pregnant woman with autoimmune polyglandular syndrome type-2 complicated by preeclampsia with severe features.
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Affiliation(s)
- David R. Bayless
- Department of Obstetrics and Gynecology , Division of Maternal-Fetal Medicine, University of Texas Medical Branch , Galveston , TX , USA
| | - Trevor M. Caldarera
- Department of Obstetrics and Gynecology , Division of Maternal-Fetal Medicine, University of Texas Medical Branch , Galveston , TX , USA
| | - Hassan M. Harirah
- Department of Obstetrics and Gynecology , Division of Maternal-Fetal Medicine, University of Texas Medical Branch , Galveston , TX , USA
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15
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Ricci J, Jones P, Le A, Steed LL, Armstrong MB, Herrera FA. Increasing Recognition of Community-Acquired, Non-Tuberculous Mycobacterial Infections of the Hand and Wrist. Cureus 2022; 14:e22105. [PMID: 35291521 PMCID: PMC8917965 DOI: 10.7759/cureus.22105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/07/2022] Open
Abstract
Background In this study, we present our experience with community-acquired, culture-positive, non-tuberculous mycobacterial (NTM) infections of the hand and wrist and compare the clinical features, risk factors, diagnostic delays, and treatment outcomes among patients referred for surgical consultation at our institution over a five-year period. Methodology We retrospectively identified patients on chart review who were diagnosed with culture-positive, extrapulmonary, cutaneous NTM infections between January 1, 2014, and December 31, 2018. Only patients with community-acquired NTM infections of the hand and wrist were included. Patient demographics, risk factors, location, diagnostic delays, NTM species isolated, treatment modalities, and treatment outcomes were collected and analyzed. These variables were further compared between patients who participated in fishing-related activities and those who did not. Results A total of 10 patients were identified with community-acquired NTM infections of the hand or wrist. Of these patients, eight (80%) were male, and six (60%) had participated in fishing-related activities prior to the initial presentation. The majority of patients had Mycobacterium marinum isolates (n = 6, 60%) and involved the hand (n = 8, 80%). M. marinum isolates were associated with a significantly shorter time to diagnosis (p = 0.02). All patients underwent surgical management with a prolonged course of postoperative antibiotics and were cured of their infection at the end of their treatment course. Conclusions Proper risk factor documentation and heightened clinical awareness are essential to reduce delays in the diagnosis of NTM skin and soft tissue infections and provide the best chance for curative therapy.
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16
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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
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17
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Jamil J, Tay CY, Bong CP, Yeap TB. Anaesthetic challenges in the spine surgery of a young Asian man with lumbar amyloidosis. BMJ Case Rep 2021; 14:e246359. [PMID: 34844969 PMCID: PMC8634329 DOI: 10.1136/bcr-2021-246359] [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: 11/11/2021] [Indexed: 11/04/2022] Open
Abstract
Primary amyloidosis is a rare systemic disorder often associated with multiple organ dysfunction. The most common form, light chain amyloidosis, has an estimated age-adjusted incidence of 5.1-12.8 cases per million person-years. Spine involvement is extremely uncommon. We present the case of a young Asian man with newly diagnosed amyloidosis involving the lumbar spine among multiple organs with a pathological vertebral fracture that required urgent spine surgery. We believe this is the first reported case to discuss the perianaesthetic challenges in the management of lumbar spine amyloidosis.
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Affiliation(s)
- Jabraan Jamil
- Anaesthesia and Intensive Care Unit, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia
| | - Chong Yan Tay
- Department of Paediatrics, Melaka General Hospital, Melaka, Malaysia
| | - Chin Pei Bong
- Department of Orthopaedics, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia
| | - Tat Boon Yeap
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
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18
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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.
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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.
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19
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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.
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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
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20
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Cortisol in Oral and Maxillofacial Surgery: A Double-Edged Sword. Int J Dent 2021; 2021:7642875. [PMID: 34545286 PMCID: PMC8448991 DOI: 10.1155/2021/7642875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/27/2021] [Indexed: 01/04/2023] Open
Abstract
Cortisol is a hormone that is naturally produced by the zona fasciculata of the cortex in the adrenal gland. One of its main functions is to decrease inflammation, particularly in areas where an inflammatory response is not necessary. In the field of oral and maxillofacial surgery, cortisol is used to improve the outcomes of surgical procedures and to make the postoperative period more comfortable for the patient. However, cortisol is considered a double-edged sword because its use is associated with both benefits and adverse effects. It is imperative to use cortisol following an accurate diagnosis, in addition to clarity regarding the desired surgical procedure for treating the acute or chronic condition affecting the patient. When used with caution, cortisol can serve as a valuable agent for reducing the postoperative inflammatory response in patients undergoing moderate as well as moderately severe surgical procedures.
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21
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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.
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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
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22
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Gupta KK, Singh A, Kalia A, Kandhola R. Anaesthetic considerations for post-COVID-19 mucormycosis surgery- A case report and review of literature. Indian J Anaesth 2021; 65:545-547. [PMID: 34321686 PMCID: PMC8312389 DOI: 10.4103/ija.ija_470_21] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/04/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Kewal K Gupta
- Baba Farid University of Health Sciences, Faridkot, Punjab, India.,Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Amanjot Singh
- Baba Farid University of Health Sciences, Faridkot, Punjab, India.,Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Akshay Kalia
- Baba Farid University of Health Sciences, Faridkot, Punjab, India.,Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
| | - Rajvir Kandhola
- Baba Farid University of Health Sciences, Faridkot, Punjab, India.,Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, India
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Aziz KT, Best MJ, Ren M, Nayar SK, Timothy Kreulen R, Gupta HO, Srikumaran U. The impact of chronic steroid use on early postoperative complications in shoulder surgery. PHYSICIAN SPORTSMED 2021; 49:223-228. [PMID: 32862751 DOI: 10.1080/00913847.2020.1811616] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Chronic steroid use has been associated with poor healing and worse long-term outcomes in patients undergoing orthopedic surgery, but the specific risk profile and short-term complications related to chronic steroids in patients undergoing outpatient shoulder surgery are inadequately defined. The purpose of this study is to characterize the effects of chronic steroids on 30-day post-operative complications following arthroscopic and open shoulder surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent arthroscopic and open rotator cuff repair, shoulder stabilization, and associated procedures from 2011 to 2018. Patients on chronic steroids were compared with patients not on chronic steroids. Demographic data and 30-day postoperative complications were analyzed. Multivariable logistic regression was used to isolate the effects of chronic steroid use on postoperative complications. RESULTS We identified 99,970 patients who underwent shoulder surgery during this period, of which 1.7% (1,662 patients) were on chronic steroids. Patients on chronic steroids were older (58.3 ± 0.30vs52.1 ± 0.05 years, p < 0.01), had higher average BMI (30.6 vs 30.1, p = 0.02), and were more likely to be female (54.9%vs38.0%, p < 0.01) and white (76.2%vs73.1%, p < 0.01). Patients on steroids had a higher American Society of Anesthesiologists class, and higher rates of diabetes, CHF, COPD, hypertension, bleeding disorders, and functionally dependency (all P < 0.01). Patients on chronic steroids were less likely to smoke (P < 0.01). Multivariable logistic regression revealed that chronic steroid use was an independent risk factor for major (OR 2.20[1.51-3.21], p < 0.001), minor (OR 2.32[1.13-3.2], p < 0.001), and infectious complications (OR 1.90[1.13-3.2], p = 0.01). CONCLUSIONS Preoperative chronic steroid use is independently associated with increased odds of major, minor, and infectious complications after open and arthroscopic rotator cuff repair, shoulder stabilization, and associated procedures. Patients on chronic steroids should be counseled about their increased risk for these complications, and both preoperative risk stratification and optimization should be employed to minimize perioperative risk.
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Affiliation(s)
- Keith T Aziz
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mark Ren
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Suresh K Nayar
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - R Timothy Kreulen
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Hari Om Gupta
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Lee HC, Yoon HK, Kim JH, Kim YH, Park HP. Comparison of intraoperative cortisol levels after preoperative hydrocortisone administration versus placebo in patients without adrenal insufficiency undergoing endoscopic transsphenoidal removal of nonfunctioning pituitary adenomas: a double-blind randomized trial. J Neurosurg 2021; 134:526-534. [PMID: 31978882 DOI: 10.3171/2019.11.jns192381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 11/15/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this double-blind randomized trial, the necessity of preoperative steroid administration in patients without adrenal insufficiency (AI) undergoing endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma was evaluated. METHODS Forty patients with and without AI, defined as a peak cortisol level > 18 µg/dl on the insulin tolerance test or rapid adrenocorticotropic hormone (ACTH) test, undergoing ETSS for nonfunctioning pituitary adenomas were randomly allocated to treatment with either 100 mg of preoperative hydrocortisone (group HC, n = 20) or normal saline (group C, n = 20). The patients with pituitary apoplexy, the use of a drug within the last 3 months that could affect the hypothalamic-pituitary-adrenal axis, or a previous history of brain or adrenal surgery were excluded. Intraoperative cortisol and ACTH levels were measured after anesthesia induction, dura incision, and tumor removal, and at the end of surgery. Intraoperative hypotension, early postoperative AI, and postoperative 3-month pituitary function were investigated. RESULTS Intraoperative serum cortisol levels were significantly higher in the HC group than in the C group after anesthesia induction (median 69.0 µg/dl [IQR 62.2-89.6 µg/dl] vs 12.7 µg/dl [IQR 8.4-18.2 µg/dl], median difference 57.5 µg/dl [95% CI 33.0-172.9 µg/dl]), after dura incision (median 53.2 µg/dl [IQR 44.9-63.8 µg/dl] vs 6.4 [IQR 4.8-9.2 µg/dl], median difference 46.6 µg/dl [95% CI 13.3-89.2 µg/dl]), after tumor removal (median 49.5 µg/dl [IQR 43.6-62.4 µg/dl] vs 9.2 µg/dl [IQR 5.75-16.7 µg/dl], median difference 39.4 µg/dl [95% CI 0.3-78.1 µg/dl]), and at the end of surgery (median 46.9 µg/dl [IQR 40.1-63.4 µg/dl] vs 16.9 µg/dl [IQR 12.1-23.2 µg/dl], median difference 32.2 µg/dl [95% CI -42.0 to 228.1 µg/dl]). Serum ACTH levels were significantly lower in group HC than in group C after anesthesia induction (median 3.9 pmol/L [IQR 1.7-5.2 pmol/L] vs 6.9 pmol/L [IQR 3.9-11.9 pmol/L], p = 0.007). No patient showed intraoperative hypotension due to AI. Early postoperative AI was observed in 3 and 5 patients in groups HC and C, respectively. The postoperative 3-month pituitary hormone outcomes including ACTH deficiency were not different between groups. CONCLUSIONS Preoperative steroid administration may be unnecessary in patients without AI undergoing ETSS for nonfunctioning pituitary adenomas. However, a further large-scale study is needed to determine whether preoperative steroid administration has a significant impact on clinically meaningful events such as perioperative AI and postoperative 3-month ACTH deficiency in these patients.Korean Clinical Trial Registry no.: KCT0002426 (https://cris.nih.go.kr/cris/).
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Affiliation(s)
| | | | | | - Yong Hwy Kim
- 3Neurosurgery, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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Hanafy A, Seejore K, Lynch J, Murray RD. Interpretation of the endocrinology of hospital inpatients. Br J Hosp Med (Lond) 2021; 82:1-12. [PMID: 33512289 DOI: 10.12968/hmed.2020.0517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Blood tests to assess the endocrine system are commonly performed in patients admitted to hospital. This may be because an endocrinopathy is thought to be aetiological in the presenting disease or suspected as an incidental occurrence by the clinician. Many patients, in addition to the pathology leading to admission, frequently have one or more comorbidities, a change in nutritional status and polypharmacy. Added to this, presentation with acute illness is a major life stress. All of these are likely to impact on one or more endocrine axes, although often only transiently. Endocrine evaluation in the vast majority of cases can be safely deferred to the outpatient setting. This article considers the most common endocrine anomalies discovered in hospital, the confounders, and provides guidance on how to investigate these further.
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Affiliation(s)
- Ahmed Hanafy
- Department of Endocrinology, Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Khyatisha Seejore
- Department of Endocrinology, Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| | - Julie Lynch
- Department of Endocrinology, Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
| | - Robert D Murray
- Department of Endocrinology, Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine (LICAMM), University of Leeds, Leeds, UK
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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.
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Affiliation(s)
- Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University School of Medicine, Anyang, Korea
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Serfozo K, Tarnal V. Anesthetic Management of Patients Undergoing Open Suboccipital Surgery. Anesthesiol Clin 2021; 39:93-111. [PMID: 33563388 DOI: 10.1016/j.anclin.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The posterior cranial fossa with its complex anatomy houses key pathways regulating consciousness, autonomic functions, motor and sensory pathways, and cerebellar centers regulating balance and gait. The most common posterior fossa pathologies for which neurosurgical intervention may be necessary include cerebellopontine angle tumors, aneurysms, and metastatic lesions. The posterior cranial fossa can be accessed from variations of the supine, lateral, park-bench, prone, and sitting positions. Notable complications from positioning include venous air embolism, paradoxic air embolism, tension pneumocephalus, nerve injuries, quadriplegia, and macroglossia. An interdisciplinary approach with careful planning, discussion, and clinical management contributes to improved outcomes and reduced complications.
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Affiliation(s)
- Kelsey Serfozo
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Vijay Tarnal
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA.
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Murphy MT, Latif U. Pain During COVID-19: A Comprehensive Review and Guide for the Interventionalist. Pain Pract 2020; 21:132-143. [PMID: 33295042 DOI: 10.1111/papr.12976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/08/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic pain, the leading cause of disability in the world, imposes limitations on activities of daily living and diminishes quality of life leading to unnecessary patient suffering. The personal and socioeconomic costs of chronic pain cannot be overstated. Physicians are at the crux of the pandemic and must attempt to limit the spread of the virus while maintaining their professional responsibility to their patients and staff members. OBJECTIVE The aim of this review is to analyze the existing literature to develop consensus recommendations for treating pain during the current COVID-19 pandemic. METHODS Relevant literature was located via computer-generated citations between the months of March and May of 2020. Online computer searches of multiple databases including Google Scholar, CINAHL, PubMed, and Cochrane Review were conducted in conjunction with a thorough review of local, state, national, and international governmental and organizational websites to locate research on the area of interest. RESULTS The guidelines in this review are meant to offer a framework to pain practitioners and organizations for providing highly effective, ethical, and safe care to patients while maintaining their commitment to mitigating the spread of the COVID-19 pandemic. Specific areas addressed include general and interventional-specific treatment and mitigation recommendations. CONCLUSIONS We believe that the recommendations in this review, if used in conjunction with evolving recommendations of Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), and federal, state, and local governing bodies, provides a path to not only mitigate the spread of the pandemic but also limit the adverse impact of pain and suffering in chronic pain patients.
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Affiliation(s)
- Micheal T Murphy
- Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
| | - Usman Latif
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, U.S.A
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29
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Ito S, Seki H, Innami Y, Ouchi T. Intraoperative refractory hypotension in a patient with chronic use of low-dose prednisolone. JA Clin Rep 2020; 6:1. [PMID: 32026044 PMCID: PMC6967263 DOI: 10.1186/s40981-019-0307-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 12/26/2019] [Indexed: 11/10/2022] Open
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30
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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.
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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
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Chua AW, Kumar CM, Chua MJ, Harrisberg BP. Anaesthesia for ophthalmic procedures in patients with thyroid eye disease. Anaesth Intensive Care 2020; 48:430-438. [PMID: 33198476 DOI: 10.1177/0310057x20957018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thyroid eye disease is an autoimmune inflammatory disorder of the orbit in adults. It causes inflammation, expansion and fibrosis of orbital fat, muscles and the lacrimal gland, leading to facial disfigurement, functional disability and, in severe cases, blindness. Overall, approximately 20% of affected patients need some form of surgical intervention requiring anaesthesia. This narrative review explores the background of thyroid eye disease, surgical procedures performed and their implications for anaesthesia. General anaesthesia is used for orbital decompression procedures, strabismus correction surgery and complex oculoplastic procedures. Local anaesthetic infiltration or regional anaesthesia under monitored anaesthesia care are the techniques most commonly employed for eyelid retraction surgery. It is important to limit the volume of local anaesthetic agent used during infiltration and continuously monitor the orbital volume and ocular pressure with a ballottement technique. In addition, the contralateral eye should be checked and, if necessary, protected against corneal exposure. Retrobulbar, peribulbar and sub-Tenon's blocks are best avoided. Topical anaesthesia has been used for some strabismus correction surgery but its use is limited to motivated and cooperative patients only.
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Affiliation(s)
- Alfred Wy Chua
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Chandra M Kumar
- Department of Anaesthetics, Khoo Teck Puat Hospital, Singapore.,Newcastle University, Newcastle upon Tyne, UK.,Newcastle University Medical School, Johor, Malaysia
| | - Matthew J Chua
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Australia
| | - Brian P Harrisberg
- Department of Ophthalmology, Royal Prince Alfred Hospital, Camperdown, Australia
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Ortoleva J. Anesthetic Considerations for Recovered COVID-19 Patients. J Cardiothorac Vasc Anesth 2020; 35:376-377. [PMID: 33183931 PMCID: PMC7581371 DOI: 10.1053/j.jvca.2020.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/17/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
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Lee R, Lee D, Gowda NB, Iweala U, Weinreb JH, Falk DP, Yu W, O'Brien JR. Increased Rates of Septic Shock, Cardiac Arrest, and Mortality Associated With Chronic Steroid Use Following Anterior Cervical Discectomy and Fusion for Cervical Stenosis. Int J Spine Surg 2020; 14:649-656. [PMID: 33046542 DOI: 10.14444/7095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is an established treatment modality for cervical spondylosis. Many patients are on immunosuppressant therapy in the management of various inflammatory spinal pathologies and other comorbid conditions. The impact of chronic steroid use on postoperative complications has not been examined in cervical fusion procedures. The objective of this study was to identify specific postoperative complications associated with steroid/immunosuppressant use following ACDF for cervical stenosis. METHODS A multi-institutional surgical registry was queried to identify 5377 patients with ACDF diagnosed with cervical stenosis. Patients were stratified into cohorts with a history of steroid/immunosuppressant use for chronic conditions (n = 198, 3.3%) versus those who did not (n = 5179, 96.7%). Propensity-score matching without replacement was implemented to control for preoperative demographics and comorbidities. Pearson χ2 and Fischer exact tests were used in comparing the prevalence of demographics, comorbidities, and complication rates. RESULTS Upon propensity matching, increased rates of pulmonary embolisms (0.51% vs 0.00%, P = .025), cardiac arrest requiring resuscitation (1.01% vs 0.10%, P = .020), septic shock (0.51% vs 0.00%, P = .025), and mortality (1.52% vs 0.20%, P = .009) in the postoperative 30-day period in patients on chronic steroid/immunosuppressant use were observed. CONCLUSIONS The results indicate that steroid use/immunosuppression in patients with ACDF has a higher associated rate of pulmonary embolisms, cardiac arrest, septic shock, and mortality. The risk of mortality and these other complications should be carefully considered prior to operative intervention. Future research may investigate steroid-tapering protocols that reduce the rate of infection and other postoperative complications in the subset of immunosuppressed ACDF patients. CLINICAL RELEVANCE By elucidating the complication rates of ACDF patients on steroids for cervical stenosis, orthopedic surgeons can better stratify patients for risk of postoperative morbidity. Surgeons may have deeper risk-benefit discussions with these specific patients before they elect to have the operation.
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Affiliation(s)
- Ryan Lee
- The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Danny Lee
- The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Nikhil B Gowda
- The George Washington University School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Uchechi Iweala
- Department of Orthopaedic Surgery, The George Washington University Hospital, Washington, District of Columbia
| | - Jeffrey H Weinreb
- Department of Orthopaedic Surgery, The George Washington University Hospital, Washington, District of Columbia
| | - David P Falk
- Department of Orthopaedic Surgery, University of Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Warren Yu
- Department of Orthopaedic Surgery, The George Washington University Hospital, Washington, District of Columbia
| | - Joseph R O'Brien
- Washington Spine and Scoliosis Clinic, OrthoBethesda, Bethesda, Maryland
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Corticosteroids in the Management of Pregnant Patients With Coronavirus Disease (COVID-19). Obstet Gynecol 2020; 136:823-826. [PMID: 32769659 DOI: 10.1097/aog.0000000000004103] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Recent evidence supports the use of an early, short course of glucocorticoids in patients with COVID-19 who require mechanical ventilation or oxygen support. As the number of coronavirus disease 2019 (COVID-19) cases continues to increase, the number of pregnant women with the disease is very likely to increase as well. Because pregnant women are at increased risk for hospitalization, intensive care unit admission, and mechanical ventilation support, obstetricians will be facing the dilemma of initiating maternal corticosteroid therapy while weighing its potential adverse effects on the fetus (or neonate if the patient is postpartum and breastfeeding). Our objective is to summarize the current evidence supporting steroid therapy in the management of patients with acute respiratory distress syndrome and COVID-19 and to elaborate on key modifications for the pregnant patient.
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Puntillo F, Giglio M, Brienza N, Viswanath O, Urits I, Kaye AD, Pergolizzi J, Paladini A, Varrassi G. Impact of COVID-19 pandemic on chronic pain management: Looking for the best way to deliver care. Best Pract Res Clin Anaesthesiol 2020; 34:529-537. [PMID: 33004164 PMCID: PMC7366114 DOI: 10.1016/j.bpa.2020.07.001] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 12/23/2022]
Abstract
Although pain treatment has been described as a fundamental human right, the Coronavirus disease 2019 (COVID-19) pandemic forced healthcare systems worldwide to redistribute healthcare resources toward intensive care units and other COVID-19 dedicated sites. As most chronic pain services were subsequently deemed non-urgent, all outpatient and elective interventional procedures have been reduced or interrupted during the COVID-19 pandemic in order to reduce the risk of viral spread. The shutdown of pain services jointly to the home lockdown imposed by governments has affected chronic pain management worldwide with additional impact on patients' psychological health. Therefore, the aim of this review is to analyze the impact of COVID-19 pandemic on chronic pain treatment and to address what types of strategies can be implemented or supported in order to overcome imposed limitations in delivery of chronic pain patient care.
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Affiliation(s)
- Filomena Puntillo
- Department of Interdisciplinary Medicine, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Mariateresa Giglio
- Anesthesia, Intensive Care and Pain Unit, Policlinico Hospital, 70124 Bari, Italy
| | - Nicola Brienza
- Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", 70124 Bari, Italy
| | - Omar Viswanath
- Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | | | | | - Giustino Varrassi
- Paolo Procacci Fdn, Via Tacito 7, 00193 Roma, Italy; World Institute of Pain, Winston-Salem, NC, USA.
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Baranidharan G, Bretherton B, Eldabe S, Mehta V, Thomson S, Sharma ML, Vajramani G, Bojanic S, Gulve A, FitzGerald J, Hall S, Firth J. The impact of the COVID-19 pandemic on patients awaiting spinal cord stimulation surgery in the United Kingdom: a multi-centre patient survey. Br J Pain 2020; 15:282-290. [PMID: 34373788 PMCID: PMC7443576 DOI: 10.1177/2049463720948092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Introduction Spinal cord stimulation (SCS) is a recommended treatment for chronic refractory neuropathic pain. During the COVID-19 pandemic, elective procedures have been postponed indefinitely both to provide capacity to deal with the emergency caseload and to avoid exposure of elective patients to COVID-19. This survey aimed to explore the effect of the pandemic on chronic pain in this group and the views of patients towards undergoing SCS treatment when routine services should resume. Methods This was a prospective, multi-centre telephone patient survey that analysed data from 330 patients with chronic pain who were on an SCS waiting list. Questions focussed on severity of pain, effect on mental health, medication consumption and reliance on support networks during the COVID-19 pandemic. Views towards undergoing SCS therapy were also ascertained. Counts and percentages were generated, and chi-square tests of independence explored the impact of COVID-19 risk (very high, high, low) on survey responses. Results Pain, mental health and patient's ability to self-manage pain deteriorated in around 47%, 50% and 38% of patients, respectively. Some patients reported increases in pain medication consumption (37%) and reliance on support network (41%). Patients showed a willingness to attend for COVID-19 testing (92%), self-isolate prior to SCS (94%) and undergo the procedure as soon as possible (76%). Conclusion Our findings suggest that even during the COVID-19 pandemic, there remains a strong clinical need for patients with chronic pain identified as likely SCS responders to be treated quickly. The current prioritisation of new SCS at category 4 (delayed more than 3 months) is challenged judging by this national survey. These patients are awaiting SCS surgery to relieve severe intractable neuropathic pain. A priority at category 3 (delayed up to 3 months) or in some selected cases, at category 2 are the appropriate priority categories.
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Affiliation(s)
- Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Beatrice Bretherton
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - Vivek Mehta
- Pain and Anaesthesia Research Centre, St Bartholomew's Hospital, London, UK
| | - Simon Thomson
- Department of Anaesthesiology, Basildon and Thurrock University Hospitals, Basildon, UK
| | - Manohar Lal Sharma
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Girish Vajramani
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Stana Bojanic
- Department of Neurosurgery, The John Radcliffe Hospital, Oxford, UK
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | - James FitzGerald
- Department of Neurosurgery, The John Radcliffe Hospital, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Samuel Hall
- Wessex Neurological Centre, University Hospital Southampton, Southampton, UK
| | - Julie Firth
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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A contextual-behavioral perspective on chronic pain during the COVID-19 pandemic and future times of mandated physical distancing. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2020. [DOI: 10.1016/j.jcbs.2020.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Prete A, Taylor AE, Bancos I, Smith DJ, Foster MA, Kohler S, Fazal-Sanderson V, Komninos J, O’Neil DM, Vassiliadi DA, Mowatt CJ, Mihai R, Fallowfield JL, Annane D, Lord JM, Keevil BG, Wass JAH, Karavitaki N, Arlt W. Prevention of Adrenal Crisis: Cortisol Responses to Major Stress Compared to Stress Dose Hydrocortisone Delivery. J Clin Endocrinol Metab 2020; 105:5805157. [PMID: 32170323 PMCID: PMC7241266 DOI: 10.1210/clinem/dgaa133] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/09/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Patients with adrenal insufficiency require increased hydrocortisone cover during major stress to avoid a life-threatening adrenal crisis. However, current treatment recommendations are not evidence-based. OBJECTIVE To identify the most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency who are exposed to major stress. DESIGN AND PARTICIPANTS Cross-sectional study: 122 unstressed healthy subjects and 288 subjects exposed to different stressors (major trauma [N = 83], sepsis [N = 100], and combat stress [N = 105]). Longitudinal study: 22 patients with preserved adrenal function undergoing elective surgery. Pharmacokinetic study: 10 patients with primary adrenal insufficiency undergoing administration of 200 mg hydrocortisone over 24 hours in 4 different delivery modes (continuous intravenous infusion; 6-hourly oral, intramuscular or intravenous bolus administration). MAIN OUTCOME MEASURE We measured total serum cortisol and cortisone, free serum cortisol, and urinary glucocorticoid metabolite excretion by mass spectrometry. Linear pharmacokinetic modeling was used to determine the most appropriate mode and dose of hydrocortisone administration in patients with adrenal insufficiency exposed to major stress. RESULTS Serum cortisol was increased in all stress conditions, with the highest values observed in surgery and sepsis. Continuous intravenous hydrocortisone was the only administration mode persistently achieving median cortisol concentrations in the range observed during major stress. Linear pharmacokinetic modeling identified continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range. CONCLUSIONS Continuous intravenous hydrocortisone infusion should be favored over intermittent bolus administration in the prevention and treatment of adrenal crisis during major stress.
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Affiliation(s)
- Alessandro Prete
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Angela E Taylor
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Irina Bancos
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - David J Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- School of Mathematics, University of Birmingham, Birmingham, UK
| | - Mark A Foster
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- Royal Centre for Defence Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - Sibylle Kohler
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Violet Fazal-Sanderson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - John Komninos
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Donna M O’Neil
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Dimitra A Vassiliadi
- Department of Endocrinology, Diabetes and Metabolism, Evangelismos Hospital, Athens, Greece
| | - Christopher J Mowatt
- Department of Anaesthesiology, Royal Shrewsbury Hospital, The Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Hospital, Oxford, UK
| | | | - Djillali Annane
- Critical Care Department, Hôpital Raymond-Poincaré, Laboratory of Infection & Inflammation U1173 INSERM/University Paris Saclay-UVSQ, Garches, France
| | - Janet M Lord
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Brian G Keevil
- Department of Clinical Biochemistry, University Hospital of South Manchester, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
| | - John A H Wass
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University of Birmingham and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence and Reprint Requests: Wiebke Arlt, MD, DSc, FRCP, FMedSci, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK. E-mail:
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Coluzzi F, Marinangeli F, Pergolizzi J. Managing chronic pain patients at the time of COVID-19 pandemic. Minerva Anestesiol 2020; 86. [DOI: 10.23736/s0375-9393.20.14666-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Allen G, Mitchell A, Ramirez M, Holsten S, Shah N. A Case of a Post-Operative Addisonian Crisis from HPA Axis Suppression from Inhaled Corticosteroids. Am Surg 2020. [DOI: 10.1177/000313481908500920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | | | - Niral Shah
- Medical College of Georgia Augusta, Georgia
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Corticosterone Inhibits LPS-Induced NLRP3 Inflammasome Priming in Macrophages by Suppressing Xanthine Oxidase. Mediators Inflamm 2020; 2020:6959741. [PMID: 32508525 PMCID: PMC7251469 DOI: 10.1155/2020/6959741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 04/27/2020] [Indexed: 12/22/2022] Open
Abstract
Following traumatic insult and associated pathogen infection, innate immunity is activated during the perioperative period, especially the NLRP3 inflammasome in macrophages. The neuroendocrine response is also rapidly activated to regulate excessive inflammation; however, the molecular mechanisms are still not completely clear. This study is aimed at investigating the modulation of NLRP3 inflammasome priming by endogenous glucocorticoids (corticosterone, CORT) and its relationship with xanthine oxidase (XO). RAW264.7 murine macrophages were stimulated with LPS (1 μg/ml). LPS-induced NLRP3 expression was pretreated by CORT at different concentrations (0-900 ng/ml). Then, the effect of higher concentrations of CORT (700 ng/ml) on LPS-induced NLRP3 expression and the effect of allopurinol (250 μg/ml) were observed. Finally, the effects of a CORT antagonist (RU486) on XO expression and activity and NLRP3 expression in macrophages were further analyzed. Supernatant levels IL-1β and IL-18 were measured. The results showed that LPS-induced NLRP3 expression was upregulated further by pretreatment with CORT (300 ng/ml) (P < 0.05); however, higher concentrations of CORT (greater than 700 ng/ml) downregulated NLRP3 expression (P < 0.01) and the expression and activity of XO (P < 0.05 and P < 0.01, respectively). Allopurinol significantly inhibited NLRP3 expression. However, XO expression and activity, NLRP3 expression, and supernatant IL-1β and IL-18 levels were significantly increased in the RU486 group compared with the CORT group. In conclusion, our results suggested that CORT inhibits LPS-induced NLRP3 inflammasome priming in macrophages. The underlying mechanism is related to the modulation of XO expression and activity, which may be involved in priming and activating the NLRP3 inflammasome.
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Pre-operative chronic opioid or glucocorticoid use and mortality after noncardiac surgery: A retrospective cohort study. Eur J Anaesthesiol 2020; 37:926-933. [PMID: 32371829 DOI: 10.1097/eja.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The chronic use of opioids and glucocorticoids is associated with serious side effects. Moreover, both medications are related to poor long-term postoperative outcomes. OBJECTIVE The study aimed to investigate the association between pre-operative chronic opioid and glucocorticoid use and 90-day mortality after noncardiac surgery. DESIGN Retrospective, population-based cohort study. SETTING Single tertiary academic hospital. PATIENTS The study enrolled adult (≥18 years of age) patients admitted to Seoul National University Bundang Hospital, between January 2012 and December 2018 for planned, elective, noncardiac surgery. MAIN OUTCOME MEASURES The study compared the 90-day mortality for patients using opioids or glucocorticoids chronically (≥3 months) prior to surgery and for opioid-naïve and glucocorticoid-naïve patients. RESULTS A total of 112 606 patients were included in the study. Among them, 107 843 (95.9%) were opioid-naïve and glucocorticoid-naïve patients; 3373 (3.0%), 1199 (1.1%) and 191 patients (0.2%) were chronic users of opioids, glucocorticoids or both, respectively. In the multivariable model, compared with opioid-naïve and glucocorticoid-naïve patients, the odds of dying within 90 days were significantly higher for chronic users of opioids [3.56-fold; 95% confidence intervals (CIs) 2.36 to 5.38; P < 0.001], glucocorticoids (4.17-fold; 95% CI 3.28 to 5.29; P < 0.001) and combined opioids and glucocorticoids (7.66-fold; 95% CI 3.91 to 15.01; P < 0.001). CONCLUSION Chronic pre-operative use of opioids and glucocorticoids, together or individually, were associated with increased 90-day mortalities after noncardiac surgery, compared with opioid-naïve and glucocorticoid-naïve patients. Our results suggest that chronic pre-operative use of opioids and glucocorticoids should be managed carefully.
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Shanthanna H, Strand NH, Provenzano DA, Lobo CA, Eldabe S, Bhatia A, Wegener J, Curtis K, Cohen SP, Narouze S. Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel. Anaesthesia 2020; 75:935-944. [PMID: 32259288 PMCID: PMC7262200 DOI: 10.1111/anae.15076] [Citation(s) in RCA: 162] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2020] [Indexed: 12/17/2022]
Abstract
Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.
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Affiliation(s)
- H Shanthanna
- Department of Anesthesia, McMaster University, ON, Canada
| | - N H Strand
- Division of Pain Medicine, Mayo Clinic Alix School of Medicine, Phoenix, AZ, USA
| | - D A Provenzano
- Pain Diagnostics and Interventional Care, Sewickley, PA, USA
| | - C A Lobo
- Department of Anaesthesiology, Hospital das Forças Armadas, Pólo Porto, Portugal
| | - S Eldabe
- Department of Pain Medicine, James Cook University Hospital, Middlesbrough, UK
| | - A Bhatia
- Comprehensive Integrated Pain Program-Interventional Pain Service, Department of Anesthesia and Pain Medicine, University of Toronto and Toronto Western Hospital, Toronto, ON, Canada
| | - J Wegener
- Department of Anesthesiology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - K Curtis
- Comprehensive Integrated Pain Program-Interventional Pain Service, Department of Anesthesia and Pain Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - S P Cohen
- Department of Anesthesiology and Critical Care Medicine, Neurology and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - S Narouze
- Northeast Ohio Medical University and Chairman, Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, OH, USA
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Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:185-195. [PMID: 32431570 DOI: 10.1007/s40140-020-00377-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of review Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence. Recent findings While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available. Summary We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.
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Lewis AL, Chaft J, Girotra M, Fischer GW. Immune checkpoint inhibitors: a narrative review of considerations for the anaesthesiologist. Br J Anaesth 2020; 124:251-260. [PMID: 32007241 PMCID: PMC7890563 DOI: 10.1016/j.bja.2019.11.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/04/2019] [Accepted: 11/15/2019] [Indexed: 02/08/2023] Open
Abstract
Immunotherapy has revolutionised the treatment of oncologic malignancies. Immune checkpoint inhibitors represent a new class of immunotherapy drugs. Although these drugs show promise, they are associated with immune-related adverse reactions. An increasing number of patients who undergo surgery will have had treatment with immune checkpoint inhibitors. In this narrative review article, we discuss their mechanism of action, therapeutic effects, pertinent toxicities, and address specific perioperative considerations for patients treated with immune checkpoint inhibitors.
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Affiliation(s)
- Alexandra L Lewis
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Jamie Chaft
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Girotra
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Gregory W Fischer
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Ng KT, Van Paassen J, Langan C, Sarode DP, Arbous MS, Alston RP, Dekkers OM. The efficacy and safety of prophylactic corticosteroids for the prevention of adverse outcomes in patients undergoing heart surgery using cardiopulmonary bypass: a systematic review and meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg 2020; 57:620-627. [DOI: 10.1093/ejcts/ezz325] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Corticosteroids are often administered prophylactically to attenuate the inflammatory response associated with cardiac surgery using cardiopulmonary bypass (CPB). However, the efficacy and safety profile of corticosteroids remain uncertain. The primary aim of this systematic review and meta-analysis was to investigate the effect of corticosteroids on mortality in adult cardiac surgery using CPB. Secondary aims were to examine the effect of corticosteroids on myocardial adverse events, pulmonary adverse events, atrial fibrillation, surgical site infection, gastrointestinal bleeding and duration of stay in the intensive care unit and hospital. Randomized controlled trials (RCTs) were systematically searched in electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science) from their inception until March 2019. Observational studies, case reports, case series and literature reviews were excluded. Sixty-two studies (n = 16 457 patients) were included in this meta-analysis. There was no significant difference in mortality between the corticosteroid and placebo groups [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.81–1.14; P = 0.65, participants = 14 693, studies = 24, evidence of certainty: moderate]. Compared to those receiving a placebo, patients who were given corticosteroids had a significantly higher incidence of myocardial adverse events (OR 1.17, 95% CI 1.03–1.33; P = 0.01, participants = 14 512, studies = 23) and a lower incidence of pulmonary adverse events (OR 0.86, 95% CI 0.75–0.98; P = 0.02, participants = 13 426, studies = 17). The incidences of atrial fibrillation (OR 0.87, 95% CI 0.81–0.94; P < 0.001, participants = 14 148, studies = 24) and surgical site infection (OR 0.81, 95% CI 0.73–0.90; P < 0.001, participants = 13 946; studies = 22) were all lower in patients who were given corticosteroids. In the present meta-analysis of 62 RCTs (16 457 patients), including the 2 major RCTs (SIRS and DECS trials: 12 001 patients), we found that prophylactic corticosteroids in cardiac surgery did not reduce mortality. The clinical significance of an increase in myocardial adverse events remains unclear as the definition of a relevant myocardial end point following cardiac surgery varied greatly between RCTs.
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Affiliation(s)
- Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Judith Van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Clare Langan
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - Deep Pramod Sarode
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - R Peter Alston
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Abstract
Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient morbidity and mortality. The most common critical endocrine abnormalities are associated with functional tumors, such as pheochromocytomas, insulinomas, and carcinoid tumors, leading to carcinoid syndrome, abnormal thyroid function, or disturbances in the hypothalamus-pituitary-adrenal axis, causing adrenal insufficiency. This article aims to discuss the pathophysiology, diagnosis, and perioperative management of pheochromocytomas, hyperthyroidism, hypothyroidism, adrenal insufficiency, carcinoid disease, and insulinomas.
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Affiliation(s)
- Dasun Peramunage
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101, USA
| | - Sara Nikravan
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101, USA; Division of Critical Care Medicine, Virginia Mason Medical Center, 1100 Ninth Avenue, B2-AN, Seattle, WA 98101, USA.
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Powelson EB, Reed MJ, Bentov I. Perioperative Management of Delirium in Geriatric Patients. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00353-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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