Originally published by our sister publication Anesthesiology News
Intraarticular and epidural steroid injections for chronic pain carry the risk for glucocorticoids spreading beyond the injection site, possibly causing adrenal insufficiency and surgical complications, according to a new study presented at 2022 PostGraduate Assembly in Anesthesiology of the New York State Society of Anesthesiologists.
The new study built on previous research that found more than 50% of patients have secondary adrenal insufficiency one week after epidural steroid injections, with failure to respond to an adrenocorticotropin stimulation test (J Clin Anesth 2013;25[8]:629-633).
The case report included in the study outlined the risks for insufficient patient disclosure of steroid injections before surgery (poster 267). A healthy 60-year-old female patient who received a brachial plexus block for a shoulder replacement surgery did not disclose her history of multiple epidural steroid injections. Throughout the procedure and perioperative period, despite “aggressive fluid resuscitation,” she needed a phenylephrine infusion to maintain a mean arterial pressure above 60 mm Hg. After surgery, tests revealed a morning serum cortisol level of 0.6 mcg/dL, indicating adrenal insufficiency.
“This patient in particular was receiving injections from multiple different physicians, not following the guidelines in terms of how often they should be getting injections to manage pain. Screening could have prevented her surgical complications,” said study investigator Alex Grieco, MD, an anesthesiologist at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Uniondale, N.Y.
Grieco noted that part of his institution’s presurgical screening is questioning patients to determine whether they have undergone spinal epidural injections within the 30 days prior to surgery. If an injection has taken place, this triggers a risk–benefit discussion with the surgeon to decide whether to proceed with or delay surgery.
After additional questioning, the case patient finally acknowledged receipt of multiple recent intraarticular and epidural steroids injections, and her hypotension resolved with hydrocortisone.
“Risk of adrenal insufficiency after epidural steroid infection is a very prominent concern in orthopedic and even endocrinological literature and practice but is under-screened for among anesthesiologists,” Grieco said.
By Myles Starr
Grieco reported no relevant financial disclosures.