key: cord-0689066-1brmi9se
authors: Hackett, Beth Ann
title: Providing Steroid/Corticosteroid Injections Safely in the Covid-19 Environment
date: 2020-05-03
journal: J Radiol Nurs
DOI: 10.1016/j.jradnu.2020.04.008
sha: 15490223765233719d184161cdf1deb22ab138f2
doc_id: 689066
cord_uid: 1brmi9se

nan

Beth Ann Hackett, DNP, APRN-BC, CRN Providing high quality patient care requires that procedures and tests be medically appropriate, are executed safely and meet the patients' goals for care. Patients must be fully involved in the decision-making process prior to any procedure being performed. [1] Prior to a patient undergoing any procedure informed consent must be obtained from the patient. The process of informed consent should include (1) describing the proposed intervention, (2) emphasizing the patient's role in decision-making, (3) discussing alternatives to the proposed intervention, (4) discussing the risks of the proposed intervention and (5) eliciting the patient's preference (usually by signature). [2] During this process, the patient must be educated on the risks, benefits, and alternatives of any given procedure or intervention and understand the information put forth. It is important that the patient understand the consequences of not undergoing the procedure to include no relief of pain and potential worsening of their disease. Obtaining Informed consent is both an ethical and legal obligation of any medical practitioners in the United States and originates from the patient's right to direct what happens to his/her body. [2] In general, patients that are more susceptible to the COVID-19 (Coronavirus) according to the American Society of Regional Anesthesia and Pain Medicine (ASRA) and European Society of Regional Anesthesia and Pain Therapy (ESRA) include:

• Chronic pain patients • Elderly patients and those with multiple comorbidities • Patients that use chronic opioid therapy which may cause immune suppression • Patients injected with steroids during interventional pain procedures [3] Therefore, there is an understandable risk for patients undergoing procedures that involve the injection of steroids. Typically steroid injections are used for a diagnosis of osteoarthritis, gout, bursitis, tendinitis, joint pain, plantar fasciitis, sciatica, or chronic low back pain. Prednisone/corticosteroid injections can offer fast-acting relief of inflamed muscles, joints, tendons, and bursa, which leads to a decrease in pain. In radiology, patients with chronic pain frequently undergo procedures which include the injection of prednisone/corticosteroids (such as methylprednisolone or triamcinolone). Prednisone/corticosteroids are anti-inflammatory agents that slow down the accumulation of cells responsible for producing inflammation. Steroids are frequently injected during pain procedures with the intention of easing pain, increasing a patient's mobility and quality of life. Procedures that require the injection of prednisone/corticosteroids which are performed in radiology, orthopedic practices, pain management as well as other practices, may include joint injections of the shoulder, knee, hip, elbow, epidural steroid injection of the cervical or lumbar spine.

In the present COVID environment, patients must be informed of the potential side effects of the injection of prednisone/corticosteroids prior to undergoing a procedure. Prednisone/corticosteroids have been shown to cause a variable degree of adrenal suppression for at least a few weeks as well as an altered immune response making them more susceptible to infection. There is a possible reduction in the immune response for up to a few weeks following the procedure. Each case is unique, and no management will cover all possibilities. Caution should be used when assessing patients for prednisone/corticosteroids injections balancing the severity of their underlying disease/comorbidities, the potential benefit and the risks including immunocompromise, and the additional risk should the patient have or become infected in the period after injection when there is likely to be an ongoing effect on the immunological system. Patients should be fully aware of the potential increased risk, the lack of clear evidence and be engaged in decision making. Likewise, practitioners should consider the risk benefits balance of such injections and under which circumstances they will continue to provide the injections in the current environment.

There is a sequence of steps that must be followed to provide high quality care for these patients. First and foremost, any patient considered a candidate to undergo a procedure must be screened for any signs and symptoms that may indicate the presence of COVID-19 or having had a recent close personal contact with a patient with suspected or confirmed COVID-19. We must inform our patients of the potential risks of undergoing the procedure. Patients must be informed of the additional risks in the current environment due to the immunosuppression caused by the injection of steroids and the increased risk for infection. After screening for COVID-19 the next most important step is assisting the patient in making an informed consent to undergo the procedure by providing this information.

At Orthopedic Associates of Middletown, we developed a separate consent form and spend additional time preceding the procedures to review information with patients regarding the immunosuppressant effect of undergoing of steroid/corticosteroids injections. Included is a discussion of the risk of contracting the COVID-19 versus the benefit of undergoing the steroid injection, a decrease in their pain level. Additionally, there is a discussion concerning how they can be proactive in preventing contracting the virus post procedure by following the Centers for Disease Control and Prevention (CDC) guidelines put forth to prevent this which include:

• Avoiding close contact with people who are sick.

• Sneezing and coughing into the fold of your elbow • Avoiding touching your eyes, nose, and mouth with unwashed hands.

• Avoid touching people who may be ill • Disinfect/sanitize surfaces regularly • Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available. We as an organization feel strongly that it is our responsibility as health care professionals to inform our patients of all aspects of the care we provide to include the risk, and avoidance of developing the Coronavirus in the present environment. We aim to provide informative quality care to our patients and assist them in making an informed decision to undergo these procedures. Please see attached our consent form.

Informed Consent

To our patients:Your health and wellness is of utmost importance to us. We at Middletown Orthopedics want to inform our patients of the potential side effects of the injection of steroids and the measures to protect yourself against serious illness. This is particularly important to understand right now considering the current COVID-19.The procedure you are about to have is an epidural steroid injection that involves the injection of prednisone or corticosteroids. A common side effect of corticosteroids like prednisone is increased risk of infections due to immunosuppression. This can occur even with relatively small amounts injected into the epidural space. Immunocompromised (sometimes referred to as "immunosuppressed") means you have a weakened immune system. For one reason or another, an immunocompromised person cannot fight infections as well as people with a healthy immune system.The risks of rare but serious infections must be weighed with the expected benefits of pain relief and functional improvement from epidural steroid injections.You can protect yourself after the procedure from developing infection by following the CDC guidelines to protect yourself from the Coronavirus:• Avoid close contact with people who are sick.• Sneezing and coughing into the fold of your elbow • Avoid touching your eyes, nose, and mouth with unwashed hands.• Avoid touching people who may be ill • Disinfect/sanitize surfaces regularly • Wash your hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available.I understand the above information and agree to have the stated procedure.