Shock doses of steroids

Re: Shock doses of steroids

Toby Birch — Tue, 24 Nov 2009 22:39:55 GMT

Relative adrenal insufficiency can occur in sick patients. Cats seem more susceptible. An ACTH stim would be nice before supplementing steroids though.

Some authors from the US appear to be avocating steroids in shock again although the exact timelime seems unclear and the steroids seem to be given almost instantly following the trauma. Not sure that this is very realistic and so still going with the evidence against using steroids in shock (with same exceptions as before).

Re: Shock doses of steroids

listhestar — Mon, 23 Nov 2009 18:44:30 GMT

With regards to steroids- apparently latest in human work (hubbie ITU pharmacist) is that in cases of severe stressful injuries when on ITU they will supplement with 'physioloical' (not sure exactly what that dose would equate to animal world) doses of steroid as there is some evidence that the adrenal gets 'burnt out' for a better term. Which makes sense because I understand alot of people need pancreatic support during ITU. That said I don't use steroids always as a first line but occasionally I have when the situation seems desperate and you have nothing to lose so to speak in trying

Lisa

Re: Shock doses of steroids

Niall Taylor — Tue, 27 Oct 2009 18:30:35 GMT

[quote user="Clive Ansell"]I would ignore practice policy and do what you think is clinically indicated and the correct thing to do. [/quote]

Practice policies are usually there for a reason. Far better to have a rational discussion with all vets in the practice about whether this policy needs updating I would have thought. That way you're more likely to get everyone on board which will help all animals, not just the ones you treat and there will be less of a chance of simply antagonising the people who started the policy for what they presumably believed were sound reasons .

Cheers,

Niall

Re: Shock doses of steroids

Clive Ansell — Tue, 27 Oct 2009 12:44:42 GMT

In my first practice we used to use dexamethasone at the rate of 2- 4 mg/kg i/v q 24hrs in shock cases, which works out at 1-2 ml/kg. We used solumedrone for acute spinal cases at the rate of 30mg/kg iv if within a few hours.

I no longer use either, instead I rely on high volumes of intravenous fluids and analgesia Acute severe spinal cases I refer as soon as possible if I can, if not possible then I may use solu medrone as no other options would be available. If they are not going to have surgery, then there is only potent anti inflammatory and analgesia available, with pts if no response.

Re: Shock doses of steroids

Hannah Wynne Richards — Tue, 27 Oct 2009 11:14:39 GMT

Laura Guess I should have said same position

Wynne

Re: Shock doses of steroids

Hannah Wynne Richards — Tue, 27 Oct 2009 11:08:03 GMT

Laura Are your practice principals out of the ark ? I can remember solu-medrone being hailed as the wonder drug over 20 years ago, but even then, the respected anaesthetists were very sceptical. Nearly everyone now uses shock doses of fluids. I can remember being in the opposite position, told off for giving high volumes of fluids even though I tried to defend myself by pointing out that my regime had been recomended by one of the best anaesthetists of all time. I guess your principals are clones of the one who criticised me !!!!!

All I can do is give you my sympathy

Wynne

Re: Shock doses of steroids

Clive Ansell — Mon, 26 Oct 2009 15:13:33 GMT

[quote user="Laura Henderson"]

I don't have a choice - it is practice policy. I know they're not the best but I still have to give them and would like some guidance as to how much everyone was using before they stopped?

[/quote]

What happens if you ignore practice policy and do not give the steroids?

I'm a locum so I guess it is easier for me, but if I really don't agree with something I don't do it, policy or not.

Re: Shock doses of steroids

Toby Birch — Sun, 25 Oct 2009 11:11:43 GMT

Although this is a contentious issue prehaps a discussion on practice policy is required. Alternatively ignore it and do what you believe is right.

Re: Shock doses of steroids

Rob Loxley — Sat, 24 Oct 2009 19:55:03 GMT

Wouldn't like to have a 'practice policy' on something so contentious.

If you are using steroids in acute spinal cord injury the advice I've had (from a DECVN) would be only MPSS, within 3hrs of injury and at 30mg/kg IV. However it wasn't a recommendation to be using steroids.

Re: Shock doses of steroids

Clive Ansell — Sat, 24 Oct 2009 16:17:30 GMT

I would ignore practice policy and do what you think is clinically indicated and the correct thing to do.

From memory the data sheet dose for Dexadreson is 1.0ml (2.0mg) per 10 kg in cats and dogs, although it also says this can be varied depending on severity and length of clinical signs?. I used to use solu-medrone in spinal cases or cases of severe shock at the rate of 30mg/kg, but no longer do so.

Re: Shock doses of steroids

Noweia — Sat, 24 Oct 2009 15:03:37 GMT

I don't have a choice - it is practice policy. I know they're not the best but I still have to give them and would like some guidance as to how much everyone was using before they stopped?

Re: Shock doses of steroids

Skeptvet — Tue, 06 Oct 2009 02:23:17 GMT

Just joining the chorus of agreement that steroids are not routinely indicated for most kinds of shock.

Re: Shock doses of steroids

Utlendigur — Mon, 05 Oct 2009 21:10:51 GMT

Ditto - don't use them routinely. I used to use them in spinal cases but stopped when the opinion in veterinary journals seemed to turn against it. The only cases I'd use them are anaphylactic shock, suspected addisons (although I'd normally try just rapid ivft while running ACTH stim, then give steroids) or severe heat stroke cases especially brachycephalics

Re: Shock doses of steroids

Clive Ansell — Mon, 05 Oct 2009 08:54:36 GMT

I know it is an area of mixed opinion, but I don't routinely use corticosteroids anymore in the treatment of shock. I concentrate on IVFT at shock rates, analgesia and sometimes supplementary oxygen along with continual monitoring for improvement.

I have found, by accident working in very busy ooh centres, with cat RTA's in particular effective analgesia (I usually use morphine if available) and oxygen and leave them alone for a little while before setting up IVFT seems to work better.

I think corticosteroids are going to interfere with treatment further down the line, impaired healing and GI complications spring to mind.

If a suspect addisonian crisis I would use dexamethasone, but would prefer hydrocortisone sodium succinate if available as it has both mineral- and gluco- corticoid activity, along with shock rates of 0.9% saline. Would of course try and get baseline serum electrolytes first.

Re: Shock doses of steroids

Toby Birch — Sun, 04 Oct 2009 23:11:49 GMT

None!

Although controversial current evidence from the human field would suggest that corticosteroids are not indicated.

In shock (not cardiogenic!) correct IVFT is the key.

In head trauma the hyperglycaemia caused by the steroids may worsen the prognosis. A large human study in the UK (CRASH trial) showed no benefit to the use of corticosteroids and potentially even a detrimental effect.

A retrospective study in veterinary medicine of steroid use in IVDD showed a higher rateof GI complications and greater hospital costs when corticosteroids were used to treat the patients with IVDD.

Some exceptions:

There has been renewed interest in corticosteroids for the treatment of septic patients with 'relative adrenal insuffiency' with increasing evidence that these patients may benefit with supplementation at physiological doses. However corticosteroids are not recommended routinely for septic shock.

Addisonian crisis: If clinical suspicion is high enough dexamethasone can be given during an ACTH stim test (Dex does not interfere with the assay but is a powerful inhibitor of the HPA axis. This means it can be given as treatment during an ACTH stimulation test but the test may be uninterpretable if dex has been given in the previous 24-48hrs). Obviously dex isn't your only treatment!

I am sure this will be controversial and I will wait for the input of others.

Toby

Re: Shock doses of steroids

Niall Taylor — Sun, 04 Oct 2009 22:43:22 GMT

Hi Laura,

What sort of emergency are you referring to? The volumes of solumedrone for spinal emergencies are very high but much of the evidence is extrapolated from human studies and the validity of the results are questionable in veterinary cases.

Cheers,

Niall