The management of the surgical patient taking glucocorticoids
- Amir H Hamrahian, MD
Amir H Hamrahian, MD
- Chief, Endocrinology
- Professor of Medicine
- Cleveland Clinic Abu Dhabi
- Sanziana Roman, MD
Sanziana Roman, MD
- Professor of Surgery (Endocrine Surgery)
- Duke University School of Medicine
- Stacey Milan, MD
Stacey Milan, MD
- Assistant Professor of Surgery (Endocrine Surgery)
- Texas Tech University Health Sciences Center El Paso
- Section Editors
- Lynnette K Nieman, MD
Lynnette K Nieman, MD
- Section Editor — Adrenal Disease
- Senior Investigator
- Bethesda, MD
- Sally E Carty, MD, FACS
Sally E Carty, MD, FACS
- Section Editor — Endocrine Surgery
- Professor, Chief, Division of Endocrine Surgery
- University of Pittsburgh School of Medicine
Chronic glucocorticoid therapy can suppress the hypothalamic-pituitary-adrenal (HPA) axis and, during times of stress such as surgery, the adrenal glands may not respond appropriately. Protocols for "stress dose" steroids followed reports in the 1950s of possible surgery-associated adrenal insufficiency due to sudden preoperative withdrawal of glucocorticoids. However, some studies have questioned the need for supplemental perioperative glucocorticoids beyond the maintenance dose.
The management of the surgical patient on chronic glucocorticoid therapy is reviewed here. Perioperative glucocorticoid regimens for patients taking replacement glucocorticoid for primary adrenal insufficiency are addressed separately. (See "Treatment of adrenal insufficiency in adults", section on 'Surgery'.)
The use of stress doses of glucocorticoids, such as 300 mg/day of hydrocortisone for several days [1-3], had become a common perioperative practice for patients on glucocorticoid therapy, based upon early case reports of intraoperative adrenal crisis after abrupt withdrawal of glucocorticoids [4,5].
However, a number of studies suggest that supplemental exogenous stress glucocorticoids may not be needed to meet the demands of perioperative stress [1,6-12]. However, all studies are limited by small numbers of patients .
Two reports suggest that stress doses may not be needed even in patients on glucocorticoids undergoing major colorectal surgery. In a 2012 retrospective cohort study of patients with inflammatory bowel disease undergoing such surgery, administration of low-dose perioperative steroids (the equivalent of their preoperative dose given intravenously), no patients required vasopressors for hemodynamic instability or additional steroids for adrenal insufficiency . In a randomized trial of similar patients undergoing major colorectal surgery, no differences in postural hypotension or adrenal insufficiency were seen between those receiving high-dose glucocorticoids (hydrocortisone 100 mg intravenously three times daily) or low-dose glucocorticoids (the equivalent of their preoperative dose given intravenously) .
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- PERIOPERATIVE GLUCOCORTICOIDS
- Potential adverse effects of perioperative glucocorticoids
- Individualized approach
- CORTISOL SECRETION DURING STRESS
- APPROACH BASED UPON HPA AXIS SUPPRESSION
- Nonsuppressed HPA axis
- Suppressed HPA axis patients
- Intermediate patients (HPA suppression unknown)
- - Glucocorticoid use in past year
- - Inhaled and topical glucocorticoids
- - Intraarticular and spinal glucocorticoid injections
- EVALUATION OF HPA AXIS SUPPRESSION
- Intermediate patients
- - Morning serum cortisol
- - ACTH stimulation tests
- Urgent or emergency surgery
- SUMMARY AND RECOMMENDATIONS