December 18, 2013

DynaMed EBM Journal Volume 8, Issue 51

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: December 18, 2013

Expiration Date: December 18, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304159G


Last week 937 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 296 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Increasing Steroid Dose Perioperatively May Not Be Necessary for Prevention of Hypotension in Patients With Recent or Current Steroid Use
Reference: Ann Surg 2014 Jan;259(1):32 (level 2 [mid-level] evidence)

Patients having major colorectal surgery while receiving steroid treatment are routinely given high-dose corticosteroids to prevent acute perioperative adrenal insufficiency. This practice has also become standard, even for patients not receiving steroids at the time of surgery but who had taken steroids in the previous year. However, high-dose steroids are associated with an increased risk of postoperative complications, such as wound infection or anastomotic dehiscence. Furthermore, observational studies in patients with inflammatory bowel disease (IBD) having colorectal surgery have previously shown no significant differences in the risk of hemodynamic instability for patients receiving high-dose steroids compared to low-dose steroids (Am J Surg 2012 Oct;204(4):481) or no steroids (Am Surg 2011 Oct;77(10):1295). Now, a prospective randomized noninferiority trial compares low-dose steroids to high-dose steroids in patients with IBD with current or recent steroid use who were scheduled to have major colorectal surgery.

A total of 121 patients with inflammatory bowel disease who were receiving steroids or were treated with steroids in the previous year were randomized to low-dose hydrocortisone (IV equivalent to presurgical oral dosing) vs. high dose hydrocortisone (100 mg IV 3 times daily). Hydrocortisone doses were gradually tapered for both groups. Among patients not taking steroids at the time of surgery, the median time from last steroid dose to surgery was 3 months for the low-dose steroid group and 4 months for the high-dose steroid group (not significant). Orthostatic, or postural, hypotension was defined as a decrease in systolic blood pressure of at least 20 mm Hg after sitting up from a supine position. Hemodynamic instability was defined as the presence of hypotension, tachycardia (heart rate > 100 beats/minute) or bradycardia (heart rate < 60 beats/minute).

The efficacy analysis excluded 29 patients (24% of those randomized) due to protocol violations or having been mistakenly randomized for a second time during a staged surgical procedure. Overall, 96% of those receiving low-dose steroids had an absence of orthostatic hypotension through postoperative day 1, compared with 95% of those receiving high-dose steroids (not significant, noninferiority criterion met). Similarly, there was an absence of orthostatic hypotension in 78% of those receiving low-dose steroids through postoperative day 7, compared with 79% of those receiving high-dose steroids (not significant). An absence of hemodynamic instability through postoperative day 7 was observed in 12% of patients in both groups. No patients in either group were treated with rescue high-dose steroids for adrenal insufficiency during the trial.

This randomized trial builds upon previous retrospective cohort studies performed by the same group, and similarly demonstrates no significant differences between low-dose and high-dose steroids for patients with IBD having major colorectal surgery with steroid use in the previous 12 months. These findings also add to those of a systematic review of 2 randomized trials and 7 cohort studies evaluating perioperative stress dose of corticosteroids in 315 patients taking daily corticosteroids. In this review, there were no differences in hemodynamic profiles in patients receiving stress dose compared to those receiving their regular steroid dose in the 2 randomized trials, and there were no episodes of unexplained hypotension or adrenal crisis in patients who did not receive stress dose in 5 cohorts studies (Arch Surg 2008 Dec;143(12):1222 full-text). Collectively, these data do not support increased perioperative dosing of steroids for the purposes of preventing adrenal insufficiency.

For more information, see the Adrenal insufficiency in adults topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

Call for Peer Reviews

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DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Cardiology
Deputy Editor of Oncology
Medical Writer
Medical Editor
Associate Editor