Prevention of adrenal crisis in stress (The PACS Study): serum cortisol during elective surgery, acute trauma and sepsis in comparison to 'stress dose' hydrocortisone administration in adrenal insufficiency

Karavitaki, Niki; Smith, David G.; Bancos, Irina; Foster, Mark; Meier, Sibylle; O’Neil, Donna M.; Komninos, John; Vassiliadi, Dimitra; Mowatt, Christopher J; Lord, Janet; Wass, John; Arlt, Wiebke

doi:10.1530/endoabs.37.gp.01.05

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“…Some experts are of the opinion that the dose of hydrocortisone administered should be higher in patients taking drugs that induce CYP3A4, and in obese adults. There is little hard evidence to guide practice, but published cases of peri‐operative adrenal crisis are available . We recommend that clinicians maintain a high index of suspicion for adrenal crises in these patients and be prepared to immediately increase the dose if necessary.…”

Section: Pharmacologymentioning

confidence: 99%

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

et al. 2020

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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.

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Section: Pharmacologymentioning

confidence: 99%

“…There is little hard evidence to guide practice, but published cases of peri-operative adrenal crisis are available [26]. We recommend that clinicians maintain a high index of suspicion for adrenal crises in these patients and be prepared to immediately increase the dose if necessary.…”

Section: Why Was This Guideline Developed?mentioning

confidence: 99%