Relationship Between Epidural Steroid Dose and Suppression of Hypothalamus-Pituitary-Adrenal Axis.

BACKGROUND: The suppression of hypothalamic-pituitary-adrenal (HPA) axis is a common complication associated with epidural steroid injections (ESIs). However, the effect of different doses is unknown. OBJECTIVES: The primary objective was to compare the differences in the duration of HPA suppression following treatment with different doses of ESI; triamcinolone acetate (TA) 40 mg and TA 20 mg. The secondary objectives were to compare the extent of salivary cortisol (SC) reduction, the incidence of adrenal insufficiency (AI), and the differences in a numeric rating scale (NRS) depending on the varying levels of TA dose used for ESI. STUDY DESIGN: A double-blind, parallel-group, randomized controlled trial. SETTING: Pain clinics in a university hospital. METHODS: The patients were treated with TA epidurally and divided into 2 groups (T20 and T40) depending on the dose of TA (20 mg and 40 mg). The SC concentration was measured before and after ESI to calculate the duration of HPA axis suppression, the extent of SC concentration reduction, and the SC recovery rate. Additionally, NRS and adrenocorticotropic hormone stimulation tests were used. RESULTS: Thirty patients were analyzed. The T40 group showed longer HPA suppression (19.7 ± 3.1 days) compared with that of the T20 group (8.0 ± 2.4 days). The recovery rate of the T40 group was lower than that of the T20 group (P < 0.015). However, there was no difference in the extent of reduction in SC concentration after ESI, the occurrence of AI, and pain reduction. LIMITATIONS: There were selection bias and no placebo control. CONCLUSIONS: Although the difference in pain relief according to the ESI dose is not significant, the HPA suppression is prolonged with a higher dose than a lower dose, and the recovery is slower. Therefore, the time interval between consecutive ESIs should be adjusted depending on the steroid dose to ameliorate the adverse effects of steroids.

Incidence of Adrenal Insufficiency and Cushing's Syndrome After Long-Term Epidural Steroid Injections Over Six Months or Longer: A Preliminary Study.

PURPOSE: Endocrinological complications of an epidural steroid injection (ESI) are rare but dangerous. Nevertheless, despite the associated risks, repeated long-term ESIs are indispensable in some clinical situations. However, only a few reports to date have assessed the safety of this procedure. In this study, we evaluate the incidence of adrenal insufficiency (AI) and Cushing's syndrome after long-term ESIs. METHODS: This clinical observational study enrolled herniated nucleus pulposus or spinal stenosis patients who had received ESIs over a period of six months or longer. The adrenocorticotropic hormone (ACTH) stimulation test was performed to confirm AI and the late-night salivary cortisol (LNSC) test was performed to diagnose Cushing's syndrome. To evaluate the hypothalamus pituitary adrenal axis suppression, salivary cortisol (SC) levels were measured on days 0, 1, 7, 21, 28, 35, and 42. RESULTS: This study included 17 patients. Among these, two patients (11.8%) developed AI, but no cases of Cushing's syndrome were reported. There was no predictor for the development of AI. The SC levels tended to increase with time after an ESI (ß = 0.003). The slope of the mixed effect model between the AI and non-AI groups showed a significant difference (p value = 0.015). However, the differences in mean SC levels at each time point between the two groups were not significant (adjusted p value = 0.053). CONCLUSION: Long-term ESI use may be associated with AI development. An unexpected adrenal crisis due to AI could be life threatening. Therefore, regular monitoring of adrenal function in patients who have received long-term ESIs may be prudent.

Head elevation by 3 vs. 6 cm in ProSeal laryngeal mask airway insertion: a randomized controlled trial.

BACKGROUND: The sniffing position (neck flexion by head elevation and head extension) is commonly used for insertion of a laryngeal mask airway. However, the appropriate degrees of head elevation and head extension are unclear. In the present study, the success rate of ProSeal™ laryngeal mask airway (LMA ProSeal) insertion using two degrees of head elevation was evaluated. METHODS: This prospective randomized, controlled study included 80 adult patients aged 18 to 90 years. In the 3 cm (n = 40) and 6 cm (n = 40) groups, the LMA ProSeal was inserted while the head was elevated 3 cm and 6 cm, respectively, using a pillow of the corresponding height. The success rate, and incidence of blood staining on cuff, sore throat and hoarseness were assessed. The alignments of laryngeal and oral axes were also evaluated. RESULTS: The first attempt success rate was higher in the 3 cm than the 6 cm group (87 % vs. 60 %, P = 0.014). In 86 % of patients in the 6 cm group and 50 % of patients in the 3 cm group in whom the second attempt failed, the third insertion attempt was successful by using a pillow height of the opposite group. The alignments of the two axes were not different between the two groups (P > 0.05). CONCLUSIONS: The first attempt success rate of ProSeal laryngeal mask insertion was higher with 3 cm than 6 cm head elevation in adult patients. TRIAL REGISTRATION: Identifiers: NCT02058030 (08/05/2015), Unique Protocol ID: phdkim1.

A pillow of 8 cm height did not improve laryngeal view and alignment of airway axes but increased anesthesiologist discomfort compared to a pillow of 4 cm height during tracheal intubation in adult patients.

BACKGROUND: Neck flexion by head elevation using an 8 to 10 cm thick pillow and head extension has been suggested to align the laryngeal, pharyngeal and oral axis and facilitate tracheal intubation. Presently, the laryngeal view and discomfort for tracheal intubation were evaluated according to two different degrees of head elevation in adult patients. METHODS: This prospective randomized, controlled study included 50 adult patients aged 18 to 90 years. After induction of anesthesia, the Cormack Lehane grade was evaluated in 25 patients using a direct laryngoscope while the patient's head was elevated with a 4 cm pillow (4 cm group) and then an 8 cm pillow (8 cm group). In the other 25 patients, the grades were evaluated in the opposite sequence and tracheal intubation was performed. The success rate and anesthesiologist's discomfort score for tracheal intubation, and laryngeal, pharyngeal and oral axes were assessed. RESULTS: There were no differences in the laryngeal view and success rate for tracheal intubation between the two groups. The discomfort score during tracheal intubation was higher in the 8 cm group when the patient's head was elevated 4 cm first and then 8 cm. The alignment of laryngeal, pharyngeal and oral axes were not different between the two degrees of head elevation. CONCLUSIONS: A pillow of 8 cm height did not improve laryngeal view and alignment of airway axes but increased the anesthesiologist discomfort, compared to a pillow of 4 cm height, during tracheal intubation in adult patients.