Steroid Cover

From Maxfaxsho.co.uk

This topic remains controversial—with lots of guidelines and opinions suggesting protocols for steroid cover of dental patients. Anna Dargue (About Us) has summarised this topic, based on the best evidence available at present.

Dental surgery causes an increase in plasma ACTH and cortisol.

However, in patients who regularly take corticosteroids (Asthma, R. Arthritis, Crohn’s, Leukaemia, Pemphigus) the HPA axis may be suppressed and so the natural stress response impaired. Without an adequate cortisol output the patient is at risk of an ‘Adrenal’ or ‘Addisonian’ crisis.

When to give steroid cover?

· It is generally accepted that HPA suppression is most likely with does of >10mg Prednisolone daily (or the equivalent.)

It is also assumed that patients who have received > 10mg Prednisolone daily within the last 3 months have some degree of HPA suppression.

(* HPA suppression can occur with high does of inhaled corticosteroids > 1.5mg/day Beclomethasone*)

Thus these patients should receive corticosteroid replacement depending on the magnitude

of surgery.

However this topic is controversial.

Addison’s Disease Patients

Patients who have Addison’s disease (hypo-pituitary and hypo-adrenal) are most at risk of developing an Adrenal crisis because of adrenal insufficiency. They have life-long dependency on replacement steroid medication.

These patients must receive additional steroids to compensate for the increased need to mount a stress response (i.e. to surgery, trauma, infection or anaesthesia.)

For Elective Treatment the recommended dose is:

Double the dose (up to 20mg hydrocortisone) of the patients steroid dose an hour before

and for 24 hours post-procedure.

Apicectomy / surgical XLA / Multiple XLA’s

25mg Hydrocortisone hemisuccinate IV just prior to the procedure

Intermediate surgery (GA Mandible / Zygoma)

25mg hydrocortisone IV at induction plus 100mg/day IV over 24 hours

Major surgery (Head and neck / Orthognathic)

25mg hydrocortisone IV at induction plus 100mg/day IV for 48 - 72 hours

• Patients maintenance oral corticosteroid restarted post-op.

• Monitor electrolytes and BP post-op.

Side-effects of long-term steroid administration are well known - they include osteoporosis, muscle weakness, cataracts, hypertension, bleeding or perforated peptic ulcers, diabetes, infections, mood changes or psychoses, delayed wound healing and immunosuppression.

References

Anaesthesia 1998; 53: 1091-104 – Peri-operative steroid supplementation - G. Nicholson, JM Burrin, GM Hall

Drugs of Therapeutics Bulletin Sept 1999, Vol 37, No.9 - Drugs in the peri-operative period

www.addisons.org.uk/publications