Steroid Cover

• Adrenal cortex:

  • Zona glomerulosa: the outermost layer -> mineralocorticoids, mainly aldosterone
  • Zona fasciculata: middle layer -> glucocorticoids -> basal level of cortisol and bursts of the hormone in response to ACTH from the anterior pituitary
  • Zona reticularis: the innermost cortical layer -> androgens, mainly dehydroepiandrosterone (DHEA)

  
• Adrenal cortex:

  • Endogenous steroids are produced by the adrenal cortex
  • If there's a lack of steroids being produced then the negative feedback loop stimulates the hypothalamus to produce corticotrophin releasing hormone, which stimulates the pituitary gland to produce adrenocorticotrophic hormone (ACTH), which then in turn stimulates the adrenal cortex to produce endogenous steroids

  
• Adrenal insufficiency = the adrenal cortex can't produce enough endogenous steroids, which are necessary to support the circulation in times of physiological stress, which could include surgery and could include certain aspects of dental surgery
• Classification of adrenal insufficiency:

  • Primary adrenal insufficiency (Addison's)
  • Secondary adrenal insufficiency
• Primary adrenal insufficiency (Addison's):

  • Autoimmune destruction of the adrenal gland
  • TB destruction
  • Destruction via malignancy
  • Iatrogenic destruction (surgical)
  • Destruction of the adrenal gland -> decreased mineralocorticoid and glucocorticoid levels in the bloodstream due to decreased production
• Primary adrenal insufficiency is characterised by mineralocorticoid deficiency and by hyperpigmentation
• Primary adrenal insufficiency (Addison's) - signs and symptoms:

  • Always tired
  • Dizzy when standing
  • Drop in blood pressure on standing
  • Inexplicable weight loss
  • Skin colour changes
  • Only eating sparingly/anorexia
  • No strength in handgrip or limbs
  • Sick or nauseous
• Primary adrenal insufficiency (Addison's) - investigations may reveal:

  • Elevated plasma ACTH (because ACTH is trying to stimulate the inactive gland)
  • Low serum sodium, and raised serum potassium
  • Adreno-cortical antibodies - often present in autoimmune adrenalitis
• Decrease in the ability of the adrenal gland to produce steroids could be caused by autoimmune destruction or could be secondary to prolonged therapy with corticosteroids - leads to adrenal suppression, adrenal atrophy and the inability to produce enough of a steroid response in response to physiological stress, which could be surgical (like dental procedures) - patients like this may need steroid cover/supplementation to make up for the deficit of the ability to reduce endogenous steroids.
• Prolonged therapy with corticosteroids -> adrenal suppression -> adrenal atrophy
• Things that constitute physiological stress:

  • Major or minor infections
  • Injury
  • Surgery
  • General anaesthesia

  
• Acute adrenal crisis:

  • Pt is acutely ill with hypotension, especially postural. They may also be very weak and confused. Feeble rapid pulse.
  • They experience anorexia, nausea, vomiting and severe abdominal pain.
  • Increased motor activity - progressing to seizures
  • Immunosuppressed organ transplant patients taking the maintenance dose of prednisolone (5-10mg/day) do not require corticosteroid cover prior to gingival surgery under local anaesthesia
  • Advocate monitoring of their blood pressure throughout the procedure
• Emergency management of an acute adrenal crisis:

  • RECOGNISE!
  • Start treatment immediately based on clinical features
  • Lay pt flat - redirect circulating volume
  • Call for help (2222 in dental hospital, 999 anywhere else)
  • ABCDE approach
  • Administratio of 200mg hydrocortisone - or approximately 4mg/kg for child
  • Fluid and electrolyte replacement is essential
• Does dental surgery qualify as stress-inducing surgery:

  • Anxiety - no - pts don't require steroid cover if they're anxious
  • LA - no significant cortisol increase during 3rd molar or periodontal surgery
  • GA - GA alone will cause an increase in cortisol levels
• Prevention of acute adrenal crisis:

  • Knowledge
  • History
  • Educating pts
  • If in doubt ask for advice
  • Consider whether treatment would be safer in a hospital unit
  • Spare medication
  • Emergency hydrocortisone injection
  • Medic alert bracelet/letter from GMP with instructions
• Dental procedures under LA on pts with steroid induced adrenal (HPA) suppression:

  • Pts with steroid induced adrenal (HPA) suppression do not require cover for dental procedures under LA
  • Essential to monitor their blood pressure and a drop >25% of diastolic blood pressure should instigate 100-200mg IV hydrocortisone cover. Ideally have IV access before start.
  • Some clinicians prefer to give steroid cover to such patients anyway.
• Dental procedures under LA on pts with primary adrenal insufficiency:

  • Minor dental procedures under LA eg straightforward cons: no change in steroid dose
  • 'Major' dental procedures under LA eg difficult extraction: double dose up to and stay at that dose for 24 hours, thereafter returning to normal dose
  • Alternatively consider 100-200mg hydrocortisone IM/IV 30 mins before procedure instead of double dose of oral steroid
• Dental procedures under GA:

  • Dental procedures under GA will generally require cover - because the act of giving GA itself is a physiologically stressful procedure
  • Typically IM hydrocortisone 100-200mg IV 1 hour prior to surgery/100-200mg IV at induction and stay at double dose for 24 hours
• Addison's clinical advisory panel recommendations:

  • Major dental surgery eg dental extraction with GA
  • 100mg hydrocortisone IM just before anaesthesia
  • Double dose oral medication for 24 hours. Then return to normal dose.
  • Dental surgery eg root canal work with LA
  • Double dose (up to 20mg hydrocortisone) one hour prior to surgery
  • Double dose oral medication for 24 hours. Then return to normal dose.
  • Minor dental procedure eg replace filling
  • Not usually required
  • An extra dose only where hypoadrenal symptoms occur afterwards.
• Additional considerations:

  • Remember infections and severe pain are considered as stress inducers within endogenous steroid secretion context
  • A pt with a significant dental abscess may require steroid supplementation: liaise with physicians
• Conclusions:

  • Liaise about patients who are taking steroids re the need for 'cover'
  • Most will not need it (exception = Addison's)
  • When in doubt, best to cover