This segment presents topics that should interest pediatric anesthesiologists of all levels written from a fellow's perspective. For this issue we have included an article reviewed by a Pediatric Fellow from The Children's Hospital in Denver. In our next segment we plan to present comments from Fellows' across the country regarding job choices post-training.
Fellows, please send your comments in reply to the following question: In one paragraph, please describe the most important factors which are guiding your job search i.e money, academics vs. private practice, free standing pediatric hospital vs. mixed case load. Replies can be sent to galinkin@email.chop.edu include your name and hospital affiliation and whether you want these included if printed.
Jeffrey Galinkin, MD
When is perioperative `steroid coverage' necessary?
Shaw M, The Cleveland Clinic Journal of Medicine 2002, 69(1):9-11.
This article reviews the perioperative management of patients on steroids. Specifically examined is recent evidence regarding the physiology of patients on steroid therapy undergoing anesthesia and surgery and the evidence of suppression of Hypophysial Pituatory Axis (HPA).
The authors first examine the basis for perioperative coverage of steroids. Daily adult production of cortisol is thought to be equivalent of 10-12 mg of hydrocortisone per day. Production rises to 50 mg/day in response to minor surgeries and up to 75-150 mg/day in response to major surgery and lasts up to 48-72 hours into the postoperative period. This response has anti-inflammatory properties as well as anti-shock characteristics. Thus, the article emphasizes a need for replacement steroids at the time of surgery.
The authors then looked at the current evidence for and against the need for perioperative steroid coverage. Multiple studies have challenged not only the dosage but also the need for steroids at all. Biochemical evidence of HPA suppression has been demonstrated in a handful of cases of perioperative hypotension and death. Other reports have shown that patients on long term steroid therapy have undergone major surgeries (including renal transplant and orthopedic surgery) uneventfully without steroid coverage. According to the authors, neither depletion of ACTH reserves or HPA suppression have been adequately demonstrated to accurately predict adrenal suppression. Evidence does support the recommendation that those receiving below 5 mg/day do not have HPA suppression and thus do not require perioperative steroid coverage. Additionally, short-term steroid therapy has not shown to suppress HPA.
The authors conclusions are based on a consensus paper form 1994. They recommend lower peak steroid doses perioperatively with a rapid return of steroid dose to baseline to parallel a normal cortisol response. A 1-3 days steroid taper is adequate for most uncomplicated cases.
Reviewed by: Zulfiqar Ahmed, MD
Pediatric Anesthesia Fellow
The Children's Hospital, Denver, CO
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