Trial Comparing Low Dose and High Dose Steroids in Patients Undergoing Colorectal Surgery

• Hemodynamic instability [ Time Frame: Through the end of hospitalization or 7 days postoperatively ] [ Designated as safety issue: Yes ]
• Postoperative Nausea [ Time Frame: Postoperative day 1 - 7 ] [ Designated as safety issue: No ]
  Measured daily Postoperative day 1 - 7 on a scale from 0 (no nausea) to 10 (nausea as bad as can be)
• Postoperative fatigue [ Time Frame: Postoperative day 1 - 7 ] [ Designated as safety issue: No ]
  Measured daily, score 0 (no fatigue) to 10 (very fatigued)
• Minor and Major medical and surgical complications [ Time Frame: Through Postoperative day 30 ] [ Designated as safety issue: Yes ]
• Length of postoperative hospitalization (days) [ Time Frame: Duration of hospital stay (expected average of 5 days) ] [ Designated as safety issue: No ]
• Hemodynamic instability [ Time Frame: From time of surgical incision to Postoperative day 7 ] [ Designated as safety issue: Yes ]
  Hemodynamic instability defined by heart rate >100 bpm, <60 bpm, Systolic blood pressure <90 mm Hg
• Postoperative Pain [ Time Frame: Postoperative day 1 - 7 ] [ Designated as safety issue: No ]
  Assessed daily by visual analog pain score (0 to 10; no pain to severe)

The purpose of this study is to evaluate the effect of low dose versus high dose steroids vital signs of patients currently on steroids or recently treated with steroids undergoing major colorectal surgery. The investigators hypothesize that there will be no statistically significant difference in orthostatic hypotension (blood pressure measured on lying, sitting, and standing), blood pressure, temperature or heart rate in the standard and low dose groups.

Our primary aim is to study the perioperative hemodynamic profile of patients on chronic steroids undergoing colon and rectal surgery. We will do this by measuring heart rate, temperature and blood pressure in the operating room and during their postoperative hospitalization. Patients will be identified in their preoperative visit. They will be randomized to high dose and low dose steroid study groups. The standard dose steroid patients will receive hydrocortisone 100 mg IV preoperatively and 100 mg IV every 8 hrs with standard taper. The low dose steroid study group will receive the IV equivalent of their preoperative steroid dose in the postoperative period. The patients blood pressure, temperature and heart rate will be monitored in the operating room and the ward postoperatively. Outcomes will be compared between the two groups. We hypothesize that there will be no statistically significant difference in blood pressure, temperature or heart rate in the high dose and low dose groups.

The secondary aim of this study will be monitoring of any differences in surgical outcomes, including postoperative length of stay, between the two patient groups.

• Orthostatic Hypotension
• Hemodynamic Instability
• Fever
• Hypothermia

• Drug: Hydrocortisone
  Patients receive Hydrocortisone 100 mg at surgical incision followed by 100mg IV every 8 hours for the first 24 hours, followed by 75 mg IV every 8 hours for 24 hours, followed by 50 mg IV every 8 hours for 24 hours, followed by 50 mg IV every 12 hours, followed by Prednisone 20 mg orally when oral diet is resumed
  Other Names:

  • Solumedrol
  • Corticosteroid
  • Steroid
• Drug: Hydrocortisone
  1/3 IV equivalent dose (IVED) (hydrocortisone equivalent of the patient's preoperative steroid dose) at surgical incision, followed by 1/3IVED for 24 hours, Patients subsequently treated with 1/4 IVED every 8 hours starting Postoperative day (POD 1), followed by 1/6 IVED every 8 hours on POD2 and every 12 hours starting POD 3. On POD 4 or when the patient was tolerating a regular diet, oral prednisone equal to the most recent IV hydrocortisone dose resumed
  Other Names:

  • Solumedrol
  • Corticosteroid
  • Steroid

• Active Comparator: High Dose Steroid
  Patients receive Hydrocortisone 100 mg at surgical incision followed by 100mg IV every 8 hours for the first 24 hours, followed by 75 mg IV every 8 hours for 24 hours, followed by 50 mg IV every 8 hours for 24 hours, followed by 50 mg IV every 12 hours, followed by Prednisone 20 mg orally when oral diet is resumed
  Intervention: Drug: Hydrocortisone
• Experimental: Low Dose Steroid
  1/3 Intravenous equivalent dose (IVED) at surgical incision, followed by 1/3IVED for 24 hours, Patients subsequently treated with 1/4 IVED every 8 hours starting Postoperative day (POD 1), followed by 1/6 IVED every 8 hours on POD2 and every 12 hours starting POD 3. On POD 4 or when the patient was tolerating a regular diet, oral prednisone equal to the most recent IV hydrocortisone dose resumed
  Intervention: Drug: Hydrocortisone

Inclusion Criteria:

• History of ulcerative colitis, inflammatory bowel disease unclassified, indeterminate colitis, or Crohn's disease;
• Major colorectal surgery, defined as surgery requiring an abdominal incision. Both open and laparoscopic procedures are eligible. Urgent and elective procedures are eligible;
• Corticosteroid therapy within 12 months of surgery;
• Able and willing to comply with all protocol procedures for the planned duration of the study
• Able and willing to understand, sign and date an informed consent document, and authorize access to protected health information.

Exclusion Criteria:

• Patients with hypotension (systolic < 90 mm Hg or diastolic < 50 mm Hg) in the preoperative area
• Patients having emergency surgery
• Children < 18 or adults > 75 years of age
• Pregnant patients
• Patients who have suffered prior hemodynamic complications of steroid withdrawal
• Other major physical or major psychiatric illness, including alcohol or substance addiction, within the last 6 months that in the opinion of the investigator would affect the patient's ability to complete the trial.
• Any condition or situation that, in the opinion of the investigator, would prevent proper evaluation of the safety or efficacy of the different steroid doses according to the study protocol
• Patients on steroids without inflammatory bowel disease