Perioperative Stress-Dose Steroids

Abstract

Supraphysiologic corticosteroid doses have routinely been considered the perioperative standard of care over the past six decades for patients on long-term steroid therapy. However, the accumulation of data over this period is beginning to suggest that such a practice may not be necessary. The majority of these studies are retrospective reviews or small prospective cohorts, but there are two small prospective, randomized placebo-controlled trials, one prospective primate trial, and several systematic reviews addressing the issue. Based on this developing evidence, patients on long-term exogenous steroids do not require high-dose perioperative corticosteroids and should instead remain on their baseline maintenance dose, with the understanding that secondary adrenal insufficiency should be considered for unexplained perioperative hypotension in these patients.

Perioperative Care of an Adolescent With 11-Beta-Hydroxylase Deficiency

“…Suppression of ACTH results in limitation of excessive mineralocorticoid and androgen production. Perioperative corticosteroid therapy is recommended to avoid cardiovascular compromise due to the stress of surgery and anesthesia [4,5]. While the time-honored therapy of patients on chronic glucocorticoid therapy has been to administer "stress doses" during the perioperative period with dosing calculated to match the maximum adrenal output (6 -8 times the basal secretion), the need for such therapy has recently been questioned with the suggestion that many patients require only the continuation of maintenance corticosteroid therapy without stress dosing [4,5].…”

“…Perioperative corticosteroid therapy is recommended to avoid cardiovascular compromise due to the stress of surgery and anesthesia [4,5]. While the time-honored therapy of patients on chronic glucocorticoid therapy has been to administer "stress doses" during the perioperative period with dosing calculated to match the maximum adrenal output (6 -8 times the basal secretion), the need for such therapy has recently been questioned with the suggestion that many patients require only the continuation of maintenance corticosteroid therapy without stress dosing [4,5]. This practice has been suggested given the potential adverse effect profile of high dose corticosteroid therapy including immune suppression, increased incidence of surgical site infections, delayed wound healing, hyperglycemia, and gastric bleeding [6][7][8].…”

Management of Chronic Medication Therapies in the Perioperative Period: a Literature Review

“…The hypothalamic-pituitary-adrenal axis is not suppressed in patients who take less than 5 mg/day of prednisone or its equivalent. Generally, patients taking more than 10 mg a day need intraoperative supplementation [14]. Surgical procedures also induce a variable range of stress; thus, the amount of supplementation should vary based on the estimated amount of surgical stress and the long-term daily dose of steroid.…”

“…Surgical procedures also induce a variable range of stress; thus, the amount of supplementation should vary based on the estimated amount of surgical stress and the long-term daily dose of steroid. It is important to consider that patients who took high-dosage steroid therapy maintain the risk adrenal of insufficiency for up to 1 year after the cessation [14].…”

Anesthesia for Colorectal Surgery

“…Steroids should be continued at the same dose throughout the perioperative period (including the morning of surgery), with higher doses (stress dose) administered only to hypotensive patients in whom arterial hypotension is unrelated to other causes (eg hypovolemia, sepsis). 26 Preoperative smoking cessation has been shown to improve outcomes, 27 but the optimal duration of preoperative abstinence still remains unclear. It is acknowledged that the implementation of such an approach in clinical practice is not always feasible because of limited hospital resources, lack of organization, and waiting time before the operation.…”