Overview
Definition:
Perioperative steroid management refers to the strategic use of glucocorticoids (e.g., hydrocortisone, prednisolone) in patients undergoing surgery, particularly those with adrenal insufficiency or on chronic corticosteroid therapy
The aim is to prevent adrenal crisis due to the physiological stress of surgery.
Epidemiology:
Approximately 0.3-0.5% of the general population are on chronic corticosteroid therapy
A significant proportion of these patients will undergo surgery at some point, making perioperative management crucial
Patients with Addison's disease or hypopituitarism are at high risk.
Clinical Significance:
Inadequate perioperative steroid coverage can precipitate an adrenal crisis, a life-threatening condition characterized by hypotension, hyponatremia, hyperkalemia, hypoglycemia, and shock
Proper management ensures physiological stability, reduces surgical stress response, and improves patient outcomes, preventing potentially fatal complications and re-operations.
Indications For Coverage
Chronic Corticosteroid Users:
Patients receiving physiological replacement doses (>5 mg/day prednisone equivalent) for more than 3 weeks within the past year
This includes patients with adrenal insufficiency (Addison's disease, hypopituitarism, post-adrenalectomy) or inflammatory conditions treated with steroids.
Sudden Steroid Withdrawal Risks:
Patients who have recently stopped corticosteroid therapy but have not had sufficient time for the hypothalamic-pituitary-adrenal (HPA) axis to recover
Recovery can take up to 12 months after discontinuation.
Certain Surgical Conditions:
Patients with severe sepsis, septic shock, or significant intra-abdominal sepsis, even if not on chronic steroids, may benefit from stress-dose steroids due to blunted HPA axis response and inflammatory processes.
Preoperative Assessment And Preparation
History Taking:
Detailed history of current steroid regimen (drug, dose, frequency, duration of use)
Symptoms suggestive of adrenal insufficiency: fatigue, weight loss, anorexia, nausea, vomiting, abdominal pain, hypotension, dizziness, hyperpigmentation
History of previous adrenal crises or surgical complications.
Physical Examination:
Vital signs (BP, pulse)
Signs of dehydration
Hyperpigmentation of skin creases or scars
Check for postural hypotension
Assess for underlying conditions requiring steroids.
Diagnostic Investigations:
Morning serum cortisol level (baseline)
ACTH stimulation test (if diagnosis is uncertain or HPA axis recovery is in question, though often deferred perioperatively)
Electrolytes (Na, K), glucose, BUN, creatinine
Consider baseline steroid dose for comparison.
Steroid Adjustment Strategy:
Continue oral steroids on the morning of surgery if feasible
For patients on hydrocortisone, consider doubling or tripling the dose or switching to IV hydrocortisone
For patients on longer-acting steroids (prednisolone, dexamethasone), switch to IV hydrocortisone
Avoid abrupt discontinuation.
Perioperative Steroid Dosing Strategies
Minor Procedures:
Continue usual oral dose or administer usual morning dose orally or IV/IM
Stress dose not typically required if patient is stable and procedure is brief with minimal physiological stress.
Moderate Procedures:
Administer hydrocortisone 50-100 mg IV/IM pre-operatively, followed by 50-100 mg every 8-12 hours for 24-48 hours
Transition back to oral regimen as tolerated.
Major Procedures:
Administer hydrocortisone 100 mg IV pre-operatively
Follow with 100 mg IV every 8 hours for the first 24-48 hours postoperatively
Gradually taper the dose over 3-5 days based on clinical condition and patient recovery.
Specific Protocols:
Some institutions use a continuous infusion of hydrocortisone (e.g., 200 mg over 24 hours) for critically ill surgical patients
Dosing should be tailored to the extent of surgery, patient's comorbidities, and clinical response.
Postoperative Management And Tapering
Monitoring:
Close monitoring of vital signs, fluid balance, electrolytes, and glucose
Assess for signs of adrenal insufficiency (hypotension, hyponatremia, hyperkalemia, hypoglycemia, nausea, vomiting, weakness).
Transition To Oral Therapy:
Once the patient is hemodynamically stable, tolerating oral intake, and improving clinically, transition from IV hydrocortisone back to the patient's usual oral glucocorticoid regimen
Start with hydrocortisone 20 mg orally daily (divided doses), or resume prior oral regimen as tolerated.
Tapering Schedule:
The duration of stress-dose steroid therapy is typically 24-72 hours
Gradual tapering is essential to allow the HPA axis to recover
Avoid rapid tapering which can precipitate adrenal insufficiency
Duration depends on the severity of stress and patient's recovery
For patients with primary adrenal insufficiency, long-term replacement is necessary.
Inability To Tolerate Oral Intake:
If oral intake is not possible, continue IV hydrocortisone
Consider fludrocortisone replacement if the patient is hypotensive and has hyponatremia or hyperkalemia, especially in primary adrenal insufficiency.
Complications And Management Of Adrenal Crisis
Signs And Symptoms:
Severe hypotension refractory to fluid resuscitation and vasopressors
Profound weakness
Nausea, vomiting, abdominal pain
Fever
Confusion or coma
Hyponatremia, hyperkalemia, hypoglycemia
Azotemia.
Management Of Adrenal Crisis:
Immediate IV fluid resuscitation (normal saline with 5% dextrose)
IV hydrocortisone 100 mg bolus, followed by continuous infusion (200 mg/24h) or intermittent IV boluses (100 mg q6-8h)
Correct electrolyte imbalances and hypoglycemia aggressively
Investigate and treat underlying precipitating cause (e.g., sepsis, surgical complication).
Prevention Strategies:
Meticulous adherence to steroid coverage protocols
Educating patients on the importance of their medication and seeking medical attention during illness or before surgery
Prompt recognition and management of any signs of adrenal insufficiency.
Key Points
Exam Focus:
Key indications for stress dosing: duration of therapy (>3 weeks), recent cessation (<1 year), specific conditions (sepsis)
Dosing of hydrocortisone (100 mg IV q8h for major surgery)
Importance of gradual tapering
Signs and management of adrenal crisis.
Clinical Pearls:
Always err on the side of caution with steroid coverage
it is safer to overtreat than undertreat
If in doubt, administer stress doses
Monitor electrolytes closely, especially sodium and potassium
Consider mineralocorticoid (fludrocortisone) needs in primary adrenal insufficiency.
Common Mistakes:
Discontinuing steroids abruptly
Inadequate dosing or duration of stress doses
Failure to taper steroids gradually
Not recognizing or managing adrenal crisis promptly
Overlooking patients with recent steroid use (even for non-endocrine conditions).