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The surgical patient taking glucocorticoids

INTRODUCTION

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, numerous studies have questioned both the need for and the doses of supplemental perioperative glucocorticoid.

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'.)

OVERVIEW

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], and the observation that glucocorticoids have a permissive effect on vascular tone and blood pressure [6]. However, a number of reports, including two randomized studies and a systematic review [7], have questioned the need for supplemental perioperative stress dose glucocorticoids [1,8-13]. The current approach is to determine perioperative glucocorticoid coverage based upon the patient’s history of glucocorticoid intake, as well as the type and duration of surgery planned [2,14-16].

In addition to suppression of the hypothalamic-pituitary-adrenal (HPA) axis, chronic glucocorticoid therapy may cause a number of other problems in the perioperative period:

Impaired wound healing [17]

               

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Literature review current through: Sep 2014. | This topic last updated: Sep 23, 2014.
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