Guidelines for the management of glucocorticoids during the peri‐operative period for patients with adrenal insufficiency

Abstract

Summary These guidelines aim to ensure that patients with adrenal insufficiency are identified and adequately supplemented with glucocorticoids during the peri‐operative period. There are two major categories of adrenal insufficiency. Primary adrenal insufficiency is due to diseases of the adrenal gland (failure of the hormone‐producing gland), and secondary adrenal insufficiency is due to deficient adrenocorticotropin hormone secretion by the pituitary gland, or deficient corticotropin‐releasing hormone secretion by the hypothalamus (failure of the regulatory centres). Patients taking physiological replacement doses of corticosteroids for either primary or secondary adrenal insufficiency are at significant risk of adrenal crisis and must be given stress doses of hydrocortisone during the peri‐operative period. Many more patients other than those with adrenal and hypothalamic–pituitary causes of adrenal failure are receiving glucocorticoids as treatment for other medical conditions. Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra‐articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency. A pragmatic approach to adrenal replacement during major stress is required; considering the evidence available, blanket recommendations would not be appropriate, and it is essential for the clinician to remember that adrenal replacement dosing following surgical stress or illness is in addition to usual steroid treatment. Patients with previously undiagnosed adrenal insufficiency sometimes present for the first time following the stress of surgery. Anaesthetists must be familiar with the symptoms and signs of acute adrenal insufficiency so that inadequate supplementation or undiagnosed adrenal insufficiency can be detected and treated promptly. Delays may prove fatal.

Peri‐operative corticosteroid supplementation for patients on therapeutic glucocorticoids: a national survey

“…We also thank Morgan et al [3] for drawing our attention to their interesting study [4]. We completely agree…”

“…Up to one-third of patients on therapeutic corticosteroids show evidence of adrenal suppression when well [2]; in theory, these patients could be unable to increase endogenous production to cover surgical stress. No robust evidencebased guidelines exist currently; recently-published national consensus guidance is based on little class A and B evidence [3].…”

“…We hypothesised that UK clinical practice was extremely variable before publication of the guidance and this insight would help optimise future study designs to address the most important uncertainties. We conducted an electronic survey (SurveyMonkey©) of the peri-operative prescribing practices of the Royal College of Anaesthetists Very few UK anaesthetists were prescribing corticosteroids in a similar regimen to that which was contained in the subsequent guidance [3]. They appeared to have a higher threshold (daily corticosteroid dose) and prescribed lower supplementary doses.…”

Guidance for the prevention and emergency management of adult patients with adrenal insufficiency

“…Surgery and sepsis are major physiological stressors, activating the hypothalamo-pituitary-adrenal axis to produce glucocorticoid, the major one being cortisol. 30 Patients with AI of any cause are unable to mount an endogenous cortisol stress response to surgery or invasive procedures, and subsequent hypotension and shock can be fatal. Therefore, all patients with AI of any cause, or considered at risk of AI, are at risk of adrenal crisis, and should be given stress doses of exogenous glucocorticoids for a surgical or invasive procedure as per the Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology, which are to maintain as near physiological concentration of cortisol as possible (Tables 2 and 3).…”

“…Therefore, all patients with AI of any cause, or considered at risk of AI, are at risk of adrenal crisis, and should be given stress doses of exogenous glucocorticoids for a surgical or invasive procedure as per the Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology, which are to maintain as near physiological concentration of cortisol as possible (Tables 2 and 3). 30,31 Patients with primary AI who are additionally aldosterone deficient may be susceptible to post-operative fluid balance issues and hyponatremia. A tendency to water retention and hyponatraemia induced by anti-diuretic hormone is very common after surgery, and thus patients with insufficient aldosterone production will be particularly susceptible to hyponatraemia.…”