Perioperative Evaluation and Management of Patients on Glucocorticoids

Abstract

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in HPA axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV Hydrocortisone 25-100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Early chest tube removal within 6 hours after thoracic surgery results in improved postoperative prognosis and no adverse effects

“…Steroids or immunosuppressants generally cause delayed wound healing ( 20 , 29 ). We hypothesized that patients who received steroids or immunosuppressants preoperatively would have more postoperative complications, but they were actuary comparable to those who did not ( Table 3 ).…”

“…Patients with high thrombotic risk received a continuous heparin infusion (5,000 units/day) immediately postoperatively. Patients taking steroids were controlled to ≤20 mg/day and perioperatively covered with steroids for preoperative risk assessments ( 20 ). Immunosuppressants were discontinued 2 weeks before the operation, and patients were controlled with steroids by endocrinologists.…”

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency

“…We base our suggested stress-dose glucocorticoid regimens on clinical practice and the guidelines from the Association of Anaesthetists, the Royal College of Physicians, the Endocrine Society and the Society for Endocrinology UK ( 38 , 126 ). However, we acknowledge that in the absence of robust evidence and head-to-head comparison of different glucocorticoid regimens, practices vary considerably among centers and lower doses are also routinely used in patients under moderate or major stress ( 127 ).…”