When patients on chronic steroid therapy show up for surgery, many of us are uncertain about what to do. As you know, when a chronic steroid-use patient presents for surgery, they carry with them a potential complication: the possibility of developing secondary adrenal insufficiency, which can translate into full-scale adrenal crisis. So, what is secondary adrenal insufficiency?
“Patients on chronic steroid therapy may experience HPAA suppression, resulting in low CRH and ACTH levels that lead to atrophy of the adrenal zona fasciculata and a decrease in cortisol production. And, as a result, inadequate cortisol production may predispose to vasodilatation and hypotension.”
Additionally, chronic steroid therapy is known “to be associated with risk of immunosuppression, impaired wound healing, hyperglycemia, and psychologic disturbances in the postoperative period.”
Given that the literature surrounding this topic is “muddied” at best, how are anesthesiologists to proceed? Will these chronic steroid-treated patients require perioperative stress-dose steroids, or not? And how will you decide what is in the patient’s best interest?
In this post, we will review the article, “Perioperative Steroid Management: Approaches Based on Current Evidence,” as well best practices for these patients based on the current evidence that we do have.
What Is the Risk in Administering Perioperative Stress-Dose Steroids?
How common is the occurrence of HPAA dysfunction? A 2001 study concluded that “perioperative hypotension due to adrenal crisis is rare, with an estimated incidence of 1 to 2%.” However, while this complication may be rare, it is potentially fatal, and must therefore be handled with great caution. As always, you must weigh your patient’s risk for adrenal crisis against the risks of unnecessary steroid supplementation.
As the literature notes, unfortunately this decision is not clear-cut, and the current textbook recommendations that we have are inconsistent and lacking in class A and B evidence. Additionally, perioperative adrenal crisis is a diagnosis of exclusion, requiring a high index of suspicion since the signs and symptoms will be largely absent and/or nonspecific in the anesthetized or postop patient.
So, given that information, how should you proceed?
A Brief History of Findings: What We Do Know About Perioperative Stress-Dose Steroids
First, the two major cases that form the foundation for much of what we think we know about perioperative stress-dose steroids are from the 1950s. Since that time, both cases have been criticized for complicating factors (i.e., withholding aggressive fluid resuscitation, vasopressors, antibiotics and the lack of biochemical proof of adrenal insufficiency via measurement of serum cortisol levels ). Studies since then have been limited and insufficiently powered to come to any clear-cut conclusions.
That said, a 1973 study of 73 minor and major surgical patients on chronic steroid therapy concluded that preoperative plasma cortisol is “not the prime determinant of the level of blood pressure in the glucocorticoid-treated patients during and after surgery, and acute stress-induced adrenocortical insufficiency is rare even when steroids are withheld.” However, limitations of this study include: (1) no agreed-upon definition of low cortisol levels; and (2) a rarely used method of measurement for cortisol levels. The study’s findings have since been criticized.
Interestingly, in 2015, an analysis of the 11,247 records in the Anesthesia Closed Claims Project database revealed that “failure to administer stress steroids generated only two claims that resulted in liability payments, and both of these cases were complicated by other issues.”
Recommendations for Perioperative Patient Care in Major Surgeries
It is important to note that unless a patient is having a major surgery, stress-dose steroids are not recommended. The term “stress dose” comes from the body receiving “the stress” and is therefore applicable to more major surgeries. Although this is true, most practitioners administer steroids because they are unaware of the data and/or they want to err on the side of caution. Given that understanding, let’s turn now to recommendations for steroid administration best practices.
Given the muddied history of findings and the lack of clear evidence, researchers and clinicians recommend a simple approach to chronic steroid-use surgical patient care. First, group your patients into four categories, and then proceed with caution from there.
Category 1: Patients With Diagnosed Secondary Adrenal Insufficiency
This should be determined by the ACTH stimulation test that is the best, most proven way of assessing the integrity of your patient’s HPAA and its function. Please note that this test is not something we typically do in the operating room setting or require before surgery. Additionally, this test has limitations, such as measuring “serum total cortisol levels rather than serum free cortisol levels”; and, at this time, the diagnostic value of free cortisol levels is not definitively proven. Additionally, the test is not yet widely available.
Category 2: High-Risk Patients for HPAA Suppression
The high-risk category includes:
- Patients taking glucocorticoid (doses equivalent to 20 mg / day or more of prednisone for more than three weeks)
- Patients with clinical features of Cushing’s syndrome
It is recommended that “unless data confirming the integrity of the HPAA is available, these patients would benefit from perioperative stress-dose steroids with dosing based on surgical stress.”
Category 3: Low-Risk Patients for HPAA Suppression
The low-risk category includes:
- Patients taking any dose of glucocorticoid for less than three weeks
- Patients taking morning doses of prednisone of 5 mg / day or less
- Patients taking prednisone of 10 mg / day every other day
For patients in this category, perioperative stress-dose steroids are not recommended unless signs of HPAA suppression are present.
Category 4: Intermediate-Risk Patients for HPAA Suppression
The intermediate-risk category includes:
- Any patients on chronic steroid therapy who do not fit into the first three categories.
In conclusion, it is debatable whether or not perioperative stress-dose steroids further increase risk in chronic steroid-use patients. It may be best practice to withhold the stress dose and consider using stress-dose steroids at the first sign of any issues during a case. For example, if there is any out-of-the-ordinary hypotension during a case, you may consider giving steroids at that time on an as-needed basis.
As always, use your best judgment when administering treatment to patients on chronic steroid therapy. While it should be noted that hydrocortisone is currently the drug of choice for stress- and rescue-dose steroid coverage, please see “Perioperative Steroid Management: Approaches Based on Current Evidence” for tables including steroid choices, potency, dosages and conversion charts to help you navigate this muddied area of perioperative patient care.
- Axelrod L: Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am 2003; 32:367–83
- Zaghiyan K, Melmed G, Murrell Z, Fleshner P: Are high- dose perioperative steroids necessary in patients undergoing colorectal surgery treated with steroid therapy within the past 12 months? Am Surg 2011; 77:1295–9
- Brown CJ, Buie WD: Perioperative stress dose steroids: Do they make a difference? J Am Coll Surg 2001; 193:678–86
- Melanie M. Liu, Andrea B. Reidy, Siavosh Saatee, Charles D. Collard; Perioperative Steroid Management: Approaches Based on Current Evidence. Anesthesiology 2017;127(1):166-172. doi: 10.1097/ALN.0000000000001659.
- de Lange DW, Kars M: Perioperative glucocorticosteroid supplementation is not supported by evidence. Eur J Intern Med 2008; 19:461–7
- Kehlet H, Binder C: Adrenocortical function and clinical course during and after surgery in unsupplemented gluco-corticoid-treated patients. Br J Anaesth 1973; 45:1043–8
- written personal communication, Karen L. Posner, Ph.D., Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, December 2015
- Liu et al.
- Hamrahian AH, Oseni TS, Arafah BM: Measurements of serum free cortisol in critically ill patients. N Engl J Med 2004; 350:1629–38
- Liu et al.