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Table of Contents
LETTER TO EDITOR
Year : 2019  |  Volume : 35  |  Issue : 4  |  Page : 560-562

Steroids for adult cardiac surgery: The debate echoes on


Department of Cardiac Anaesthesia, Cardiothoracic Centre, CNC, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Web Publication13-Dec-2019

Correspondence Address:
Dr. Arindam Choudhury
Department of Cardiac Anaesthesia, Cardio Thoracic Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joacp.JOACP_268_19

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How to cite this article:
Magoon R, Choudhury A, Sahoo S, Malik V. Steroids for adult cardiac surgery: The debate echoes on. J Anaesthesiol Clin Pharmacol 2019;35:560-2

How to cite this URL:
Magoon R, Choudhury A, Sahoo S, Malik V. Steroids for adult cardiac surgery: The debate echoes on. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2020 Jan 25];35:560-2. Available from: http://www.joacp.org/text.asp?2019/35/4/560/272937



Madam,

The recent era is characterised by an on-going search of interventions that contribute to an improved outcome. Perioperative outcome metrics in the adult cardiac surgical arena are revamping with the continuous refinement of the anesthetic, surgical and perfusion regimes. However, certain practices like prophylactic steroids for attenuation of the systemic inflammatory response to cardiopulmonary bypass have been extensively studied with inconclusive evidence.

Steroids have long been considered as 'magic bullets' against inflammation and are being administered in cardiac surgery for almost past four decades now. This instinctive application has been increasingly interrogated considering the advancements such as heparin coated circuits, membrane oxygenators, centrifugal pumps and modified ultrafiltration aimed at minimizing the pro-inflammatory potential of CPB. Moreover, the myriad of systemic effects attributable to the steroid administration have challenged the prophylactic use furthermore, particularly in diabetics and those prone to infection.

The literature surrounding the evaluation of steroids for adult cardiac surgery recites an interesting tale. The initial meta-analyses included considerably heterogeneous studies demonstrating primary attention to intermediate endpoints rather than appropriate patient effects leading to a lack of robust evidence.[1],[2] This accounted for the escalating empiricism with regards to the steroids amounting to an augmented global variation. This inconsistency in the practice prompted two large multicentre randomised clinical trials (RCT), DExamethasone for Cardiac Surgery (DECS) trial[3] and Steroids In cardiac Surgery (SIRS) trial.[4] The results of the RCTs are depicted in [Table 1]. Both the trials did not reveal improved primary outcomes. However, a reduced incidence of pulmonary infection and hospital stay was discovered with dexamethasone administration in the DECS trial.
Table 1: A comparison of the DECS and SIRS trial[3],[4]

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The recent 2018 meta-analysis including 56 RCTs published since the 1970s also failed to demonstrate any clear beneficial impact of steroids on the mortality after cardiac surgery.[5] DECS and SIRS trials constituted 75% of the total number of study subjects in the meta-analysis accounting for the pattern of the similarity in results. However, the index meta- analysis triggered a few controversies. The analysis depicted an elevated risk of myocardial injury with steroids in sharp contrast to the previous meta-analysis. It is noteworthy that the SIRS trial also incurred an incremental risk of myocardial injury, with the DECS showing no significant risk of myocardial injury with dexamethasone. The reason elucidated was the heterogeneity in the definition of this outcome considering that SIRS employed creatinine kinase-fraction MB (CK-MB) levels and not mandated more sensitive and specific cardiac troponins. The meta-analysis also reported lower incidence of new onset atrial fibrillation (AF) in the steroid group in background of a statement that the larger trials failed to demonstrate this observation again suggesting a debatable generalisation.

To conclude, the steroid debate continues to snowball with fewer answers and newer questions. It is seductively easy to warrant focussed research in an area of controversy albeit the conglomeration of multitude of factors affecting the outcomes under evaluation with an intervention continue to pose a formidable challenge. The fraternity ardently anticipates more of science and less of empiricism enterprising the application of steroids in adult cardiac surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cappabianca G, Rotunno C, De Luca Tupputi Schinosa L, Ranieri VM, Paparella D. Protective effects of steroids in cardiac surgery: A meta-analysis of randomised double-blind trials. J Cardiothorac Vasc Anesth 2011;25:156-65.  Back to cited text no. 1
    
2.
Ho KM, Tan JA. Benefits and risks of corticosteroid prophylaxis in adult cardiac surgery: A dose-response meta-analysis. Circulation 2009;119:1853-66.  Back to cited text no. 2
    
3.
Dieleman JM, Nierich AP, Rosseel PM, van der Maaten JM, Hofland J, Diephuis JC, et al. Dexamethasone for Cardiac Surgery (DECS) Study Group. Intraoperative high-dose dexamethasone for cardiac surgery: A randomised controlled trial. JAMA 2012;308:1761-67.  Back to cited text no. 3
    
4.
Whitlock RP, Devereaux PJ, Teoh KH, Lamy A, Vincent J, Pogue J,et al. SIRS Investigators. Methylprednisolone in patients undergoing cardiopulmonary bypass (SIRS): A randomised, double-blind, placebo-controlled trial. Lancet 2015;386:1243-53.  Back to cited text no. 4
    
5.
Dvirnik N, Belley-Cote EP, Hanif H, Devereaux PJ, Lamy A, Dieleman JM, et al. Steroids in cardiac surgery: A systematic review and meta-analysis. Br J Anaesth 2018;120:657-67.  Back to cited text no. 5
    



 
 
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