Perioperative Corticosteroid Administration Research Articles

Perioperative corticosteroids for reducing postoperative complications following esophagectomy: an updated systematic review and meta-analysis

BackgroundThis updated systematic review and meta-analysis aims to evaluate the efficacy and safety of perioperative corticosteroid administration versus placebo for esophageal cancer patients following scheduled esophagectomy.MethodsWe searched databases through June 30, 2023. We included articles on randomized controlled trials (RCTs) comparing perioperative corticosteroid administration with placebo in esophageal cancer patients with esophagectomy. The outcomes were the death rate during hospitalization, length of hospital stay, and short-term complications. Risk ratios (RRs) and corresponding 95% confidence interval (CIs) for each estimated effect size were applied for dichotomous outcomes, and the mean difference (MD) and corresponding 95% CIs for each estimated effect size were applied for continuous outcomes. We used GRADE to evaluate the quality of each of the outcome and the level of recommendations.ResultsNine RCTs with 508 participants were included in this study. Severe outcomes, including the length of hospital stay, leakage, mortality during the hospitalization period in the corticosteroid group was comparable to that in the control group, but positive effects of corticosteroid administration were observed on the length of intensive care unit stay (MD -3.1, 95% CI − 5.43 to − 0.77), cardiovascular disorders (RR 0.44, 95% CI 0.21–0.94) and other general complications (RR 0.49, 95% CI 0.29–0.85).ConclusionsPeri-operative intravenous corticosteroid administration may reduce cardiovascular disorders, other general complications and the length of ICU stay without carrying severe outcomes. More high quality RCTs are warranted to further investigate the effects of corticosteroids on postoperative mortality and complications for esophageal cancer patients with esophagectomy.Systematic review registrationCochrane, registration number: 196.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy.

The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Low incidence of postoperative nausea, vomiting, regurgitation, and aspiration pneumonia in geriatric dogs receiving maropitant, famotidine, and fentanyl as part of an anesthesia protocol.

To determine the incidence of and potential risk factors for postoperative regurgitation and vomiting (PORV), postoperative nausea and vomiting (PONV), and aspiration pneumonia in geriatric dogs using premedication with maropitant and famotidine, intraoperative fentanyl, and postoperative fentanyl as part of an anesthetic protocol. 105 client-owned geriatric dogs that underwent general anesthesia for a major surgical procedure between January 2019 and March 2020. Medical records were reviewed to collect data on signalment, historical gastrointestinal signs, American Society of Anesthesiologists (ASA) score, indication for surgery, duration of anesthesia and surgery, patient position during surgery, mode of ventilation, and perioperative administration of maropitant, famotidine, anticholinergics, opioids, colloidal support, NSAID, corticosteroids, and appetite stimulants. The incidence of postoperative regurgitation, vomiting, nausea, and aspiration pneumonia was calculated, and variables were each analyzed for their association with these outcomes. 2 of 105 (1.9%) dogs regurgitated, 1 of 105 (1.0%) dogs developed aspiration pneumonia, 4 of 105 (3.8%) dogs exhibited nausea, and no dogs vomited. Identified possible risk factors included older age (≥ 13 years old) for postoperative regurgitation, regurgitation for postoperative aspiration pneumonia, and high ASA score (≥ 4) for both regurgitation and aspiration pneumonia. The use of an antiemetic protocol including maropitant, famotidine, and fentanyl in geriatric dogs resulted in very low incidences of PORV, PONV, and aspiration pneumonia. Future prospective studies are warranted to further evaluate and mitigate postoperative risks.

Anatomical and functional outcomes in combined rhegmatogenous retinal and choroidal detachment pre-treated with systemic corticosteroid: a case series.

Combined rhegmatogenous retinal and choroidal detachment (CRRCD) is a rare phenomenon. It is important that CRRCD is recognised preoperatively so that corticosteroids may be administered as this may make repair surgery easier to do. We here report on the anatomical and visual outcomes of 3 patients treated for CRRCD. Retrospective review of 3 eyes of 3 patients with CRRCD which underwent scleral buckle, vitrectomy, and silicone oil insertion. Data including visual acuity, intraocular pressure, ocular inflammatory status, the presence of subretinal fluid, the presence of retinal breaks, the presence of proliferative vitreoretinopathy, demographic information, medical and ophthalmic history, administration of perioperative corticosteroids, surgical techniques, and complications was collected. Patients were aged 60, 66, and 62years old at the time of surgery. There was a minimum follow-up time of 20months. Initial visual acuity was 4/60. Initial intraocular pressure was 3mmHg, 7mmHg, and 7mmHg. All eyes had deep, inflamed anterior chambers at the time of presentation. All eyes underwent 20-gauge vitrectomy, scleral buckle, and silicone oil insertion. All patients received a perioperative course of oral corticosteroids. Final visual acuity was 6/12, 6/7.5, and 6/18. These 3 patients had good anatomical and functional results following surgery for CRRCD. All patients had visual acuity of 6/18 or better at last review.

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies

BackgroundPerioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA). MethodsA systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used. Results201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = −0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = −0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. ConclusionUse of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.

Perioperative Corticosteroids Reduce Dysphagia Severity Following Anterior Cervical Spinal Fusion: A Meta-Analysis of Randomized Controlled Trials.

The anterior approach to the cervical spine is commonly used to treat cervical pathology. It is, however, associated with high rates of dysphagia, which may be associated with substantial patient morbidity. Perioperative corticosteroid administration has been advocated to decrease dysphagia rates; its efficacy, however, remains uncertain. We conducted a meta-analysis of randomized trials to determine the efficacy of perioperative corticosteroid administration in reducing postoperative dysphagia as well as any adverse effects, such as pseudarthrosis and infection. We conducted a systematic search of electronic databases (MEDLINE, Embase, CENTRAL [Cochrane Central Register of Controlled Trials], ClinicalTrials.gov) to identify randomized controlled trials (RCTs) that evaluated corticosteroids versus any comparator for prevention of postoperative dysphagia after anterior cervical spine procedures. Two independent reviewers used the GRADE (Grades of Recommendation Assessment, Development and Evaluation) criteria to assess eligibility and risk of bias, perform data extraction, and rate the quality of evidence. The primary outcome was severity of postoperative dysphagia. We conducted meta-analyses of dysphagia (both overall and by delivery method), pseudarthrosis, and postoperative infection. After screening of 927 articles, a total of 7 studies were eligible for final inclusion. These included 431 patients, of whom 247 received corticosteroids and 184 received placebo or a control treatment. Moderate-quality evidence demonstrated a significant improvement in postoperative dysphagia rates (odds ratio, 0.35; 95% confidence interval, 0.20 to 0.63; p < 0.001), and this finding was robust to both permutation analyses and sensitivity analyses removing the studies with a high risk of bias. There was no significant difference between intravenous and local steroid administration (p = 0.16). There were no documented infections. There was no significantly increased risk of pseudarthrosis in those receiving steroids compared with placebo or a control treatment (p = 0.13). This meta-analysis found moderate-quality evidence supporting the use of perioperative corticosteroid administration as an adjunct to anterior cervical spinal procedures. Patients treated with corticosteroids intravenously or locally had significantly decreased severity of dysphagia. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

The Effects of Perioperative Corticosteroids on Dysphagia Following Surgical Procedures Involving the Anterior Cervical Spine: A Prospective, Randomized, Controlled, Double-Blinded Clinical Trial.

Dysphagia is one of the most common complications of surgical procedures in the anterior cervical spine, and can persist up to 2 years postoperatively. Corticosteroids are relatively safe and inexpensive for treating various inflammatory conditions. Perioperative corticosteroid administration for anterior cervical spine procedures may effectively minimize postoperative dysphagia, potentially leading to better outcomes, decreased readmission rates, and improved patient satisfaction. The purpose of this study was to determine the efficacy of perioperative corticosteroids in decreasing the severity and duration of dysphagia following single-level and multilevel anterior cervical spine procedures. Seventy-four patients undergoing elective anterior cervical surgical procedures for degenerative conditions were recruited. Patients with prior cervical procedures; with a diagnosis of fracture, malignancy, or infection; or requiring combined anterior-posterior procedures were excluded. Patients were randomized to perioperative intravenous dexamethasone or saline solution. Doses were administered before incision and at 8 and 16 hours postoperatively. Investigators and patients were blinded to the treatment throughout the study. Dysphagia outcomes were assessed with use of the Bazaz dysphagia scale and the Dysphagia Short Questionnaire (DSQ) at 1 day, 2 days, 1 week, 2 weeks, 1 month, 3 months, 6 months, and 12 months postoperatively. Statistical analysis was performed comparing means and standard deviations; significance was set at p < 0.05. Clinical outcomes were measured with use of the Quality of Life-12 and Neck Disability Index. Sixty-four patients were included in the analysis. There were 49 anterior cervical discectomies and fusions, 8 corpectomies, 1 hybrid procedure (corpectomy and adjacent discectomy), and 6 single-level arthroplasties. Patients who received corticosteroids had significantly better dysphagia scores on both the Bazaz scale and DSQ at most time points up to 6 months postoperatively (p < 0.05). On subgroup analysis, patients with multilevel (≥2-level) fusion benefited significantly from corticosteroids on both scales, whereas those with single-level procedures did not. There were no short-term wound complications or infections, and length of stay and fusion rates were comparable. Perioperative administration of corticosteroids can reduce dysphagia symptoms following multilevel anterior cervical procedures. Benefit was noted immediately and up to 6 months postoperatively. There was no significant effect on short-term wound-healing, infection rates, length of stay, or fusion rates. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PACMAN trial protocol, Perioperative Administration of Corticotherapy on Morbidity and mortality After Non-cardiac major surgery: a randomised, multicentre, double-blind, superiority study

IntroductionPostoperative complications are major healthcare problems and are associated with a reduced short-term and long-term survival after surgery. An excessive postoperative inflammatory response participates to the development of postoperative infection...

Acute post-operative airway complications following anterior cervical spine surgery and the role for cricothyrotomy.

Anterior cervical spine surgery (ACSS) is a common procedure, but not without its own risks and complications. Complications that can cause airway compromise occur infrequently, but can rapidly lead to respiratory arrest, leading to severe morbidity or death. Knowing emergent post-operative airway management including surgical airway placement is critical. We aim to review the different etiologies of post-operative airway compromise following ACSS, the predictable timeline in which they occur, and the most appropriate treatment and management for each. We place special emphasis on the timing and proper surgical technique for an emergent cricothyrotomy. Angioedema is seen the earliest as a cause of post-operative airway compromise, typically within 6-12 hours. Retropharyngeal hematomas can be seen between 6-24 hours, most commonly within 12 hours. Pharyngolaryngeal edema is seen within 24-72 hours. After 72 hours, retropharyngeal abscess is the most likely etiology. Several studies have utilized delayed extubation protocols following ACSS based on patient risk factors and found reduced postoperative airway complications and reintubation rates. The administration of perioperative corticosteroids continues to be controversial with high-level studies recommending both for and against their use. Animal studies showed that after cardiac arrest, the brain can recover if oxygenation is restored within 5 minutes, but this time is likely shorter with asphyxia prior to cardiac arrest. Experience and training are essential to reduce the time for successful cricothyrotomy placement. Physicians must be prepared to diagnose and treat acute postoperative airway complications following ACSS to prevent anoxic brain injury or death. If emergent intubation cannot be accomplished on the first attempt, physicians should not delay placement of a surgical airway such as cricothyrotomy.

Perioperative corticosteroid management for patients with inflammatory bowel disease.

Guidelines on the appropriate use of perioperative steroids in patients with inflammatory bowel disease (IBD) are lacking. As a result, corticosteroid supplementation during and after colorectal surgery procedures has been shown to be highly variable. A clearer understanding of the indications for perioperative corticosteroid administration relative to preoperative corticosteroid dosing and duration of therapy is essential. In this review, we outline the basic tenets of the hypothalamic-pituitary-adrenal (HPA) axis and its normal response to stress, describe how corticosteroid use is thought to affect this system, and provide an overview of the currently available data on perioperative corticosteroid supplementation including the limited evidence pertaining to patients with inflammatory bowel disease. Based on currently existing data, we define "adrenal suppression," and propose a patient-based approach to perioperative corticosteroid management in the inflammatory bowel disease population based on an individual's historical use of corticosteroids, the type of surgery they are undergoing, and HPA axis testing when applicable. Patients without adrenal suppression (<5 mg prednisone per day) do not require extra corticosteroid supplementation in the perioperative period; patients with adrenal suppression (>20 mg prednisone per day) should be treated with additional perioperative corticosteroid coverage above their baseline home regimen; and patients with unclear HPA axis function (>5 and <20 mg prednisone per day) should undergo preoperative HPA axis testing to determine the best management practices. The proposed management algorithm attempts to balance the risks of adrenal insufficiency and immunosuppression.

Perioperative corticosteroids for preventing complications following facial plastic surgery.

Early recovery is an important factor for people undergoing facial plastic surgery. However, the normal inflammatory processes that are a consequence of surgery commonly cause oedema (swelling) and ecchymosis (bruising), which are undesirable complications. Severe oedema and ecchymosis delay full recovery, and may make patients dissatisfied with procedures. Perioperative corticosteroids have been used in facial plastic surgery with the aim of preventing oedema and ecchymosis. To determine the effects, including safety, of perioperative administration of corticosteroids for preventing complications following facial plastic surgery in adults. In January 2014, we searched the following electronic databases: the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase; EBSCO CINAHL; and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). There were no restrictions on the basis of date or language of publication. We included RCTs that compared the administration of perioperative systemic corticosteroids with another intervention, no intervention or placebo in facial plastic surgery. Two review authors independently screened the trials for inclusion in the review, appraised trial quality and extracted data. We included 10 trials, with a total of 422 participants, that addressed two of the outcomes of interest to this review: swelling (oedema) and bruising (ecchymosis). Nine studies on rhinoplasty used a variety of different types, and doses, of corticosteroids. Overall, the results of the included studies showed that there is some evidence that perioperative administration of corticosteroids decreases formation of oedema over the first two postoperative days. Meta-analysis was only possible for two studies, with a total of 60 participants, and showed that a single perioperative dose of 10 mg dexamethasone decreased oedema formation in the first two days after surgery (SMD = -1.16, 95% CI: -1.71 to -0.61, low quality evidence). The evidence for ecchymosis was less consistent across the studies, with some contradictory results, but overall there was some evidence that perioperatively administered corticosteroids decreased ecchymosis formation over the first two days after surgery (SMD = -1.06, 95% CI:-1.47 to -0.65, two studies, 60 participants, low quality evidence ). The difference was not maintained after this initial period. One study, with 40 participants, showed that high doses of methylprednisolone (over 250 mg) decreased both ecchymosis and oedema between the first and seventh postoperative days. The only study that assessed facelift surgery identified no positive effect on oedema with preoperative administration of corticosteroids. Five trials did not report on harmful (adverse) effects; four trials reported that there were no adverse effects; and one trial reported adverse effects in two participants treated with corticosteroids as well as in four participants treated with placebo. None of the studies reported recovery time, patient satisfaction or quality of life. The studies included were all at an unclear risk of selection bias and at low risk of bias for other domains. There is limited evidence for rhinoplasty that a single perioperative dose of corticosteroids decreases oedema and ecchymosis formation over the first two postoperative days, but the difference is not maintained after this period. There is also limited evidence that high doses of corticosteroids decrease both ecchymosis and oedema between the first and seventh postoperative days. The clinical significance of this decrease is unknown and there is little evidence available regarding the safety of this intervention. More studies are needed because at present the available evidence does not support the use of corticosteroids for prevention of complications following facial plastic surgery.

Role of Corticosteroids during Cardiopulmonary Bypass

Corticosteroids are commonly used in the peri-operative setting for patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). The inflammatory response to CPB is associated with organ dysfunction and increased mortality. Corticosteroids reduce biochemical inflammatory markers associated with CPB, however the impact on clinical outcomes is mixed. The purpose of this article is to evaluate the evidence of changes in clinical outcomes associated with the peri-operative administration of corticosteroids in patients undergoing cardiac surgery with CPB. Randomized, placebo-controlled trials and meta-analyses were reviewed for evidence evaluating the impact of corticosteroids on clinical outcomes including mortality, myocardial infarction, atrial fibrillation (AF), duration of intubation, length of intensive care unit (ICU) or hospital stay, hyperglycemia, and gastrointestinal complications. Most of the relevant studies are underpowered to assess major clinical outcomes. Although corticosteroids likely reduce the risk of AF, this needs to be evaluated when used in addition to or in lieu of other anti-arrhythmic agents. Evidence does not equivocally support the use of corticosteroids to improve clinical outcomes in cardiac surgery patients.

Perioperative corticosteroids for preventing complications following facial plastic surgery

BACKGROUND: Early recovery is an important factor for people undergoing facial plastic. However, the normal inflammatory processes that are a consequence of surgery commonly cause oedema (swelling) and ecchymosis (bruising), which are undesirable complications. Severe oedema and ecchymosis delay full recovery, and may make patients dissatisfied with procedures. Perioperative corticosteroids have been used in facial plastic surgery with the aim of preventing oedema and ecchymosis. OBJECTIVES: To determine the effects, including safety, of perioperative administration of corticosteroids for preventing complications following facial plastic surgery in adults. METHODS: Search strategy: In January 2014, we searched the following electronic databases: the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase; EBSCO CINAHL; and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS). There were no restrictions on the basis of date or language of publication. Selection criteria: We included RCTs that compared the administration of perioperative systemic corticosteroids with another intervention, no intervention or placebo in facial plastic surgery. ata collection and analysis: Two review authors independently screened the trials for inclusion in the review, appraised trial quality and extracted data. MAIN RESULTS: We included 10 trials, with a total of 422 participants, that addressed two of the outcomes of interest to this review: swelling (oedema) and bruising (ecchymosis). Nine studies on rhinoplasty used a variety of different types, and doses, of corticosteroids. Overall, the results of the included studies showed that there is some evidence that perioperative administration of corticosteroids decreases formation of oedema over the first two postoperative days. Meta-analysis was only possible for two studies, with a total of 60 participants, and showed that a single perioperative dose of 10 mg dexamethasone decreased oedema formation in the first two days after surgery (SMD = -1.16, 95% CI: -1.71 to -0.61, low quality evidence). The evidence for ecchymosis was less consistent across the studies, with some contradictory results, but overall there was some evidence that perioperatively administered corticosteroids decreased ecchymosis formation over the first two days after surgery (SMD = -1.06, 95% CI:-1.47 to -0.65, two studies, 60 participants, low quality evidence). The difference was not maintained after this initial period. One study, with 40 participants, showed that high doses of methylprednisolone (over 250 mg) decreased both ecchymosis and oedema between the first and seventh postoperative days. The only study that assessed facelift surgery identified no positive effect on oedema with preoperative administration of corticosteroids. Five trials did not report on harmful (adverse) effects; four trials reported that there were no adverse effects; and one trial reported adverse effects in two participants treated with corticosteroids as well as in four participants treated with placebo. None of the studies reported recovery time, patient satisfaction or quality of life. The studies included were all at an unclear risk of selection bias and at low risk of bias for other domains. AUTHORS' CONCLUSIONS: There is limited evidence for rhinoplasty that a single perioperative dose of corticosteroids decreases oedema and ecchymosis formation over the first two postoperative days, but the difference is not maintained after this period. There is also limited evidence that high doses of corticosteroids decrease both ecchymosis and oedema between the first and seventh postoperative days. The clinical significance of this decrease is unknown and there is little evidence available regarding the safety of this intervention. More studies are needed because at present the available evidence does not support the use of corticosteroids for prevention of complications following facial plastic surgery.

Risk factors for wound infection in surgery for spinal metastasis

Wound infection rates are generally higher in patients undergoing surgery for spinal metastasis. Risk factors of wound infection in these patients are poorly understood. To identify demographic and clinical variables that may be associated with patients experiencing a higher wound infection rate. Retrospective study with prospectively collected data of spinal metastasis patients operated consecutively at a University Teaching Hospital, adult spine division which is a tertiary referral centre for complex spinal surgery. Ninety-eight patients were all surgically treated, consecutively from January 2009 to September 2011. Three patients had to be excluded due to inadequate data. Physiological measures, with presence or absence of microbiologically proven infection. Various demographic and clinical data were recorded, including age, serum albumin level, blood total lymphocyte count, corticosteroid intake, Malnutrition Universal Screening Tool (MUST) score, neurological disability, skin closure material used, levels of surgery and administration of peri-operative corticosteroids. No funding was received from any sources for this study and as far as we are aware, there are no potential conflict of interest-associated biases in this study. Higher probabilities of infection were associated with low albumin level, seven or more levels of surgery, use of delayed/non-absorbable skin closure material and presence of neurological disability. Of these factors, levels of surgery were found to be statistically significant at the 5% significance level. Risk of infection is high (17.9%) in patients undergoing surgery for spinal metastasis. Seven or more vertebral levels of surgery increase the risk of infection significantly (p<0.05). Low albumin level and presence of neurological disability appear to show a trend towards increased risk of infection. Use of absorbable skin closure material, age, low lymphocyte count, peri-operative administration of corticosteroids and MUST score do not appear to influence the risk of infection.

Perioperative corticosteroids administration as a risk factor for pressure ulcers in cardiovascular surgical patients: a retrospective study

The aim of this study was to investigate the relationship between perioperative corticosteroids administration and the incidence of pressure ulcers (PUs) in cardiovascular surgical patients. A retrospective analysis was performed on data from consecutive patients who had cardiac surgery in 2012. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between perioperative corticosteroid administration and the incidence of surgery-related PU (SRPU). A total of 286 cardiac surgery patients were included in this study; of these, 47 patients developed 57 SRPUs, an incidence of 16·4% [95% confidence interval (CI): 12·3-21·2%). The SRPU incidence was significantly higher in corticosteroid-administered group compared with groups not receiving corticosteroids (43·8% versus 14·8%, Pearson's χ(2) = 9·209, P = 0·002). The crude odds ratio (OR) was 4·472 (95% CI: 1·576-12·694). After performing multivariate logistic regression analysis, the adjusted OR was 2·808 (95% CI: 1·062-11·769). This result showed that perioperative corticosteroid administration was an independent risk factor for PUs in cardiovascular surgical patients. Therefore, it is recommended that in order to prevent PU perioperative corticosteroids should be administered with caution to cardiovascular surgical patients.

Effect of perioperative glucocorticoid administration on postoperative complications following esophagectomy: A meta-analysis

Perioperative corticosteroid administration is a controversial therapy for improving the short-term prognosis following surgery. The objective of the current meta-analysis was to evaluate the effects of the perioperative use of corticosteroids during esophagectomy for esophageal carcinoma. A comprehensive study was performed using references selected from the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, MEDLINE (Ovid databases), EMBASE and three Chinese databases (Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure and VIP Database for Chinese Technical Periodicals). Eligible studies were restricted to randomized clinical trials that reported data from patients undergoing esophagectomy. In addition, treated groups of patients received perioperative corticosteroid administration and control groups received a placebo infusion, such as saline water. The studies evaluated the incidence of postoperative complications and the variation of inflammatory mediators. All extracted data underwent meta-analysis using Review Manager 5.1 software. Only six studies were eligible for selection. The following parameters were found to be reduced following the use of methylprednisolone: Interleukin (IL)-6 immediately following surgery and on postoperative days (PODs) 1 and 3; IL-8 immediately following surgery; and PaO2/FiO2 on POD 3. Moreover, organ failure, cardiovascular complications and pulmonary morbidity were all reduced in patients with corticosteroid usage. Certain factors showed no significant differences between the treated and control groups, including IL-8 on POD 1, IL-6 prior to surgery and on POD 5, PaO2/FiO2 following surgery, mortality, anastomotic leakage, severe infection and renal and hepatic failure. Prophylactic administration of methylprednisolone during the perioperative period may reduce the incidence of specific types of postoperative complications and inhibit the postoperative inflammatory reaction. Additional randomized controlled trials must be performed.

Is perioperative corticosteroid administration associated with a reduced incidence of postoperative atrial fibrillation in adult cardiac surgery?: Table 1:

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Is perioperative corticosteroid administration associated with a reduced incidence of postoperative atrial fibrillation (POAF) in adult cardiac surgery? A total of 70 papers were identified using the search as described below. Of these, eight were identified to provide best evidence to answer the clinical question. These papers consisted of well-designed, double-blinded randomized control trials (RCTs) or meta-analysis of RCTs that presented sufficient data to reach conclusions regarding the issues of interest for this review. Postoperative atrial fibrillation occurrence, outcomes and complications were included in the assessment. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. Literature search showed that the prophylactic use of hydrocortisone (100 mg/day, 4 days) can reduce the incidence of POAF to 30%, compared with 48% in the control group (P = 0.004). One gram of methylprednisolone before surgery followed by 4 mg of dexamethasone every 6 h for 1 day after surgery was also associated with a significant reduction in POAF (21 vs 51%; P = 0.003). Moreover, a single dose of dexamethasone (0.6 mg/kg) can significantly diminish POAF (18.95 vs 32.3%; P = 0.027). The changes in POAF appeared greatest in patients receiving intermediate doses of corticosteroid (50-210 mg of dexamethasone equivalent), while both lower (up to 8 mg) and higher (236-2850 mg) dosing resulted in blunted effects. Similarly, a moderate dose of hydrocortisone (200-1000 mg/day) is as effective as high (1001-10 000 mg/day) and very high doses (10 000 mg/day). Although the optimal dose, dosing interval and duration of therapy are unclear, meta-analysis suggests that a single dose can be as effective as multiple doses. No statistically significant complications associated with the use of corticosteroids were reported in any of the studies. We conclude that a single prophylactic moderate dose of corticosteroid (50-210 mg of dexamethasone equivalent or 200-1000 mg/day hydrocortisone) can significantly reduce the risk of POAF with no significant increase in morbidity or mortality.

Variations in Perioperative Steroid Management among Surgical Subspecialists

Previously we demonstrated consistency in perioperative steroid dosing among colon and rectal surgeons. To determine whether patterns have changed and if dosing schedules differ across surgical specialties, we evaluated multiple specialties. Questionnaires were mailed to members of the American Society of Colon and Rectal Surgeons (CRS) (n = 1523), American Society of Transplant Surgeons (TS) (n = 988), American Society of General Surgeons (GS) (n = 2750), and American Association of Endocrine Surgeons (ES) (n = 278). Surveys addressed demographic factors and factors in dosing, whether steroids are managed by surgeon alone or in collaboration with colleagues, and the most common taper regimens used. Four hundred fifty surveys were returned. Sixty-four respondents had retired or answered less than 50 per cent; 386 (211CRS, 116GS, 45TS, and 14ES) were available for analysis. The majority managed both perioperative (85.5%) and tapers (77%) themselves; TS and ES were significantly less likely to use other physicians (P < 0.001). The preoperative dose used most frequently was 100 mg hydrocortisone intravenously (76% CRS, 64% GS, 22% TS, and 93% ES). Most CRS (44.5%) and GS (24.1%) taper intravenous steroids over 3 days, whereas TS (33.3%) and ES (50%) return patients to prednisone within 1 to 2 days. Discharge steroid use was inconsistent with CRS (46.4%) tapering prednisone over greater than 21 days, GS (19%) over less than 21 days, and TS (20%) and ES (21.4%) taper over 21 days to preoperative prednisone doses (P < 0.001). In the absence of standard guidelines for perioperative corticosteroid administration, significant variations exist in the regimens used by surgeons in multiple specialties.

REGRESSION OF PRIMARY CENTRAL NERVOUS SYSTEM GERMINOMA AFTER DEXAMETHASONE ADMINISTRATION: A Case Report

Childhood central nervous system (CNS) germinoma are highly curable brain tumors characterized pathologically by varying degrees of lymphocytic infiltration. The authors present a case of a CNS germinoma with significant regression in size following surgery and administration of dexamethasone, prior to initiation of chemotherapy or irradiation. The authors speculate the possible mechanism involved in its occurrence. Perioperative corticosteroid administration in patients with CNS germinoma may obfuscate the increase in response demonstrated with various chemotherapy regimens or with irradiation in CNS germinomas.

Perioperative Steroid Dosing in Patients Receiving Chronic Oral Steroids, Undergoing Outpatient Hand Surgery

ISTORICALLY, PATIENTS WHO are receiving oral glucocorticoids and undergo surgical procedures were administered supplemental intravenous steroids during the perioperative period. This practice remains controversial, however, for less invasive outpatient procedures such as those performed by hand surgeons on a routine basis. 1–5 To date, there are no evidence-based treatment guidelines that provide firm recommendations for the administration of perioperative steroids; rather, present management is based on case reports and observational studies. 2,3 In this article, we discuss the pathophysiology behind acute adrenal insufficiency, the stress response and its suppression, patients who may be at risk, the effect of inhaled and topical steroids, and published data that guide our practice concerning the administration of perioperative corticosteroids to patients undergoing outpatient hand surgery. PATHOPHYSIOLOGY The “HPA axis” consists of the hypothalamus, pituitary gland, and adrenal glands. The hypothalamus secretes corticotropin-releasing hormone (CRH) in response to stress, circulating blood levels of cortisol, and the sleep/ wake cycle. CRH then stimulates the pituitary to secrete adrenocorticotropic hormone (ACTH), which in turn stimulates the release of cortisol from the adrenal cortex. Cortisol is a negative inhibitor of both CRH and ACTH. It acts through various intracellular receptors to prevent the proliferation of T-cells, counteract insulin by increasing gluconeogenesis, promote breakdown of