Perioperative Glucocorticoid Coverage A Reassessment 42 Years After Emergence of a Problem

Abstract

ObjectiveThe authors review the historical basis for the provision of perioperative glucocorticoid coverage, and detail the evolution in the understanding of the role of the hypothalamic-pituitary-adrenal cortical (HPA) axis in response to physical stressors. New recommendations are proposed for glucocorticoid-dependent patients who require anesthesia and surgery. Summary Background DataIn 1952, a patient developed surgery-associated adrenal insufficiency as a result of preoperative withdrawal from glucocorticoid therapy. That case report, and one other in the ensuing 12 months, prompted the publication of recommendations for perioperative glucocorticoid coverage, which became the standard of care. The understanding of the role of the HPA axis in the stress response has been subsequently refined; however, recommendations for perioperative glucocorticoid coverage have not been altered in parallel. MethodsStudies were identified beginning with the first reports of the physiologic actions of the adrenal glands (1855) and the description and clinical use of cortisone . Studies were selected for review if they were related to or evaluated the provision of stress-related glucocorticoid administration. All clinical studies were evaluated to determine the basis for the provision of perioperative glucocorticoid coverage and the validity of the data used to justify these conclusions. ConclusionsClinical and experimental evidence support the concept that the current amount of perioperative glucocorticoid coverage is excessive and has been based on anecdotal information. New recommendations are proposed which suggest that the amount and duration of glucocorticoid coverage should be determined by: a) the preoperative dose of glucocorticoid taken by the 416

Adrenal Crisis: Still a Deadly Event in the 21st Century

“…34 Cortisol requirements have been best studied in patients undergoing surgery. Mean cortisol production in a normal person increases from 10 mg/day to 50 mg/day with minor operations (<1 hour), and to 75-200 mg/day after major surgery, 35 and return to high normal values by about 48-72 hours after surgery. 36 Current guidelines ( Table 5) are based on expert opinion, and dosages of glucocorticoid replacement depend on the expected stress.…”

Perioperative management of immunosuppression in rheumatic diseases—what to do?

“…Therefore, dosages of about 7.5 mg of prednisolone per day might not be problematic with respect to protracted wound healing. The often cited recommendation of perioperative supraphysiologic GC replacement doses of Salem et al [19] is not supported by evidence and was recently questioned [20] for its adverse effects on metabolism, immune function and anti-proliferative effects. However, it is common practice to give a stress dose of GC intraoperatively of about 3 times of the usual daily dose and tapering quickly over 2 to 3 days to the usual daily dose of GC.…”

Retirada da corticoterapia: recomendações para a prática clínica

“…39 One of the most often cited studies is a review published in 1994 by Salem et al, which bases its recommendations on different "degrees" of surgical stress, which have been adapted to their clinical equivalent in terms of severity. 50 According to these authors, adolescents and adults should be given 25 mg/day of hydrocortisone when subjected to surgical procedures considered of mild stress (inguinal herniorrhaphy, for example); 50-75 mg/day when subjected to moderate stress surgery (non-laparoscopic cholecystectomy, for example); and 100-150 mg/day when high stress surgery is carried out (heart surgery, for example). The hydrocortisone should be administered every 8 hours for 1-3 days, being withdrawn or returned to the normal dose as soon as the stress is removed.…”

“…The hydrocortisone should be administered every 8 hours for 1-3 days, being withdrawn or returned to the normal dose as soon as the stress is removed. 50 Another regime, also for adults, recommends doubling or tripling the glucocorticoid dose during mild to moderate stress, using 100-150 mg of hydrocortisone via continuous venous infusion in the presence of severe stress or inability to use the oral route. 11 Goichot et al 23 and Salem et al 50 ) …”