Steroids in cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory reaction that may contribute to postoperative complications. Preventing this reaction with steroids may improve outcomes. We performed a systematic review to evaluate the impact of prophylactic steroids on clinical outcomes in patients undergoing on-pump cardiac surgery. METHODS: We searched MEDLINE, EMBASE, and Cochrane CENTRAL for randomised controlled trials (RCTs) comparing perioperative corticosteroid administration with a control group in adults undergoing CPB. Outcomes of interest included mortality, myocardial infarction, and new onset atrial fibrillation. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Fifty-six RCTs published between 1977 and 2015 were included in this meta-analysis. Mortality was not significantly different between groups [3.0% (215/7258 patients) in the steroid group and 3.5% (252/7202 patients) in the placebo group; relative risk (RR), 0.85; 95% confidence interval (CI), 0.71-1.01; P=0.07; I2 = 0%]. Myocardial injury was more frequent in the steroid group [8.0% (560/6989 patients), compared with 6.9% (476/6929 patients); RR, 1.17, 95% CI, 1.04-1.31; P=0.008; I2=0%]. New onset atrial fibrillation was lower in the steroid group [25.7% (1792/6984 patients) compared with 28.3% (1969/6964 patients), RR, 0.91, 95% CI, 0.86-0.96, P=0.0005, I2=43%]; this beneficial effect was limited to small trials (P for interaction <0.00001). CONCLUSIONS: After randomising 16 013 patients, steroid administration at the time of cardiac surgery had an unclear impact on mortality, increased the risk of myocardial injury, and the impact on atrial fibrillation should be viewed with caution given that large trials showed no effect.

Cefazolin use in patients who report a non-IgE mediated penicillin allergy: a retrospective look at adverse reactions in arthroplasty.

BACKGROUND: A large number of patients presenting for total hip and knee arthroplasty report an allergy to penicillin. the reported incidence of cross reactions with cephalosporins in patients with penicillin allergy ranges from 3% to 18%. Perioperative antibiotic prophylaxis practices range from using cephalosporins to substituting clindamycin or vancomycin. the purpose of this study was to determine whether cefazolin can be used safely in the perioperative setting in patients with reported non-IgE mediated reactions to penicillin. METHODS: We retrospectively reviewed all primary total hip and knee arthroplasty (2012) and revision (278) cases done at a canadian university hospital from 2007 to 2010. We calculated the prevalence of reported penicillin allergy, the specific reaction reported, and the observed reaction rate in penicillin allergic patients given cefazolin. RESULTS: The prevalence of reported penicillin allergy was 9.9%. there was a wide range of reported reactions, with 25% IgE mediated and 75% non-IgE mediated. Only 27% of patients reporting penicillin allergies were given cefazolin. there were no adverse reactions when non-IgE mediated penicillin allergy patients received cefazolin. CONCLUSION: surgical patients with reported non-IgE allergic reactions to penicillin have a low chance of adverse reaction to perioperative administration of cefazolin. Only a fraction of surgical patients with reported non-IgE mediated reactions to penicillin receive cefazolin perioperatively.