Adrenocortical Function and Clinical Course During and After Surgery in Unsupplemented Glucocorticoid-Treated Patients

Corticosteroid Therapy in Severe Illness

“…In most patients, serum cortisol concentrations increase to levels above 18 m g per deciliter after the administration of corticotropin, [38][39][40] but in those with high base-line serum cortisol concentrations, the increment after corticotropin administration may be small, a finding that might have a predictive value with regard to mortality. 5 Among 32 patients with septic shock, all but 1 of whom had basal serum cortisol concentrations above 11 m g per deciliter (303 nmol per liter), all 13 who had a poor response to corticotropin (increase in serum cortisol, less than 9 m g per deciliter [248 nmol per liter]) died.…”

“…When blood pressure during and after surgery is taken as Unexplained circulatory instability Discrepancy between the anticipated severity of the disease and the present state of the patient, including nausea, vomiting, orthostatic hypotension, dehydration, abdominal or flank pain (indicating acute adrenal hemorrhage), fatigue, and weight loss High fever without apparent cause (negative cultures), not responding to antibiotic therapy Unexplained mental changes: apathy or depression without a specific psychiatric disturbance Vitiligo, altered pigmentation, loss of axillary or pubic hair, hypothyroidism, hypogonadism Hypoglycemia, hyponatremia, hyperkalemia, neutropenia, eosinophilia the end point, neither basal nor corticotropin-stimulated serum cortisol concentrations predict changes in blood pressure in corticosteroid-treated patients undergoing surgical stress without corticosteroid supplementation. 40,73,79 A number of case histories and more extensive studies of corticosteroid-treated patients 5,[9][10][11]25,40,[81][82][83] describe the catastrophic effects of hypocortisolism during surgery and the dramatic beneficial effects of corticosteroid therapy. In retrospect, however, many confounding factors were present that make the interpretation of these reports difficult.…”

“…In adults the adrenal glands produce about 50 mg (138 mmol) of cortisol per 24 hours during minor surgical procedures and 75 to 150 mg (207 to 414 mmol) per 24 hours during major surgery 40 ; cortisol secretion in the first 24 hours after surgery seldom exceeds 200 to 300 mg (552 to 828 mmol), 9,40 suggesting that in critically ill patients those are the maximal doses of hydrocortisone that should be administered, preferably as a continuous intravenous infusion. The reasons for withholding higher doses include the catabolic effects of high doses on muscle and wound healing, the anti-insulin effects on glucose metabolism, and the antiinflammatory effects that may allow infections to worsen.…”

“…9 A special group of patients consists of those who receive corticosteroids topically (by inhalation, intranasally, transdermally, or by enema). Hypothalamic-pituitary-adrenal suppression is very rare in these patients, 5,40 and it seems safe to withhold additional corticosteroid during minor or moderate surgical procedures or illnesses in these patients, as long as their clinical course is uncomplicated.…”

Peri‐operative steroid supplementation

“…Traditional views were again challenged by Kehlet in the 1970s who studied patients on glucocorticoid therapy, for unspecified reasons, undergoing surgery without supplementary steroid cover [7]. Although eight patients out of 104 developed intra-operative hypotension, only one patient showed concomitantly low corticosteroid values.…”