HUNTINGTON BEACH, CALIF. – For the past several decades, surgical patients have been given supraphysiologic perioperative steroid doses to prevent cardiovascular collapse, but results of a recent pilot study suggest it’s time to rethink the high-dose dogma.
There were two case reports in the 1950s of cardiovascular collapse and death in patients who were abruptly taken off steroids just before surgery (JAMA 1952;149:1542-3; Ann. Intern. Med. 1953;39:116-26).
"We don’t know what exactly happened to those patients, [but] if you look at a lot of the surgical textbooks, they’ll recommend high-dose steroids," sometimes in the range of 100-mg IV hydrocortisone every 8 hours, explained Dr. Karen Zaghiyan, a surgery resident at Cedars-Sinai Medical Center in Los Angeles, in an interview.
The problem is that steroids pose risks such as wound infection and delayed healing, plus hypertension, hyperglycemia, and psychosis, among others.
Until now, there’s been "no good evidence to support [the move] one way or the other," Dr. Zaghiyan said.
She and her colleagues at Cedars-Sinai eschewed high-dose perioperative steroids in 26 inflammatory bowel disease (IBD) patients who underwent 32 colorectal procedures, including 10 ileocolic resections and 9 ileal pouch anal anastomoses. Dr. Zaghiyan presented the results of their study at the annual Academic Surgical Congress.
The patients’ median age was 40 years, and 19 were men.
In all, 22 operations were done on patients who had been off steroids 1-12 months (median, 6 months); those patients got no perioperative steroids. Ten operations were done on patients taking 5-40 mg of prednisone daily (median, 23 mg); those patients remained on the IV hydrocortisone equivalent of their customary dose, followed by a postoperative taper.
There was no cardiovascular collapse in the perioperative period, and there was no need for vasopressors or steroid rescue. Although there were hemodynamic problems, they did not appear to be related to adrenal insufficiency.
Three patients became hypotensive because of operative or postoperative bleeding; their systolic blood pressure dropped below 90 mmHg, but they responded to transfusions. Another case of hypotension responded to fluid bolus; a fifth resolved on its own and may have been the result of a faulty blood pressure reading.
Heart rates temporarily topped 120 beats per minute in five patients and fell below 60 bpm in eight; the tachy- and bradycardia were not associated with hypotension, and resolved without intervention.
Temperatures climbed above 100.4° F in nine patients, but fevers resolved with simple cooling measures or acetaminophen. There was no hypothermia.
If any of those problems were caused by adrenal insufficiency, resolving them would have required steroids, Dr. Zaghiyan said.
"Steroid-treated IBD patients undergoing major colorectal surgery appear to have no clinically significant hemodynamic instability when treated with low-dose perioperative steroids. Management of these patients with perioperative low-dose steroids appears to be safe," Dr. Zaghiyan concluded.
The findings did not surprise Dr. Stefan Holubar, a colorectal surgeon at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., who has been trying low-dose steroids in his own IBD surgical cases.
"I thought [this study] was really fantastic. It adds some evidence" to a practice that is gaining acceptance among colorectal surgeons after "being adopted from the transplant literature. It hasn’t really been studied in colorectal surgery," Dr. Holubar said.
"I think we overtreat patients with steroids," but although it may be okay to give low-dose steroids, it may be inappropriate to give nothing, he said, adding that more research is needed.
Dr. Zaghiyan and her colleagues have begun to enroll 120 IBD patients into a prospective trial that will randomize patients to low- or high-dose perioperative steroids. In addition to hemodynamic instability, they will investigate more subtle signs of adrenal insufficiency, including nausea, vomiting, and lethargy.
They plan to publish their interim results later this year.
Dr. Zaghiyan and Dr. Holubar said they have no conflicts of interest.