Providing Steroid/Corticosteroid Injections Safely in the COVID-19 Environment

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 before any procedure being performed (Fowler, Levin, & Sepucha, 2011). Before 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) (Shah et al., 2020). 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 (Shah et al., 2020).

In general, patients who are more susceptible to the COVID-19 (coronavirus) according to the American Society of Regional Anesthesia and Pain Medicine and European Society of Regional Anesthesia and Pain Therapy include the following:

• •Chronic pain patients,
• •Elderly patients and those with multiple comorbidities,
• •Patients who use chronic opioid therapy which may cause immune suppression,
• •Patients injected with steroids during interventional pain procedures (Shanthanna et al., n.d.).

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, and elbow, and 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 before 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 after 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 (Figure 1 ) 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. In addition, there is a discussion concerning how they can be proactive in preventing contracting the virus after the procedure by following the Centers for Disease Control and Prevention guidelines put forth to prevent this which include the following:

• •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.

Figure 1.

Consent form for epidural steroid injection during COVID -19.

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.