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Perioperative Steroid Management | Anesthesiology | American Society of Anesthesiologists - Hypothalamic-Pituitary-Adrenal Axis Suppression |
Prednisone before surgery
Perioperative Management of the Surgical Patient on Chronic Steroid Therapy
However, these potential clinical benefits must be weighed against possible adverse effects. Objective: To conduct a risk-benefit analysis using a meta-analysis, to compare complication rates and clinical advantages associated with the use of high dose methylprednisolone in surgical patients.
Methods: Randomised controlled trials of high dose methylprednisolone in elective and trauma surgery were systematically searched for in various literature databases. Outcome data on adverse effects, postoperative pain and hospital stay were extracted and statistically pooled in fixed-effects meta-analyses. Results: We located 51 studies in elective cardiac and noncardiac surgery, as well as traumatology.
Pooled data failed to show any significant increase in complication rates. The only significant finding was a reduction of pulmonary complications risk difference Conclusion: For patients undergoing surgical procedures, a perioperative single-shot administration of high dose methylprednisolone is not associated with a significant increase in the incidence of adverse effects. In patients with multiple fractures, limited evidence suggests promising benefits of glucocorticoids on pulmonary complications.
Gov't Systematic Review.
❾-50%}Prednisone before surgery. Precautions for Patients on Steroids Undergoing Surgery
Recent data suggest that stress-dose steroids may not be necessary, even in patients with confirmed preoperative secondary HPAA suppression. Marik and Varon 17 suggest that most patients receiving chronic steroid therapy do not need preoperative evaluation of their adrenocortical function unless there is clinical reason to believe that it might affect perioperative management, as this testing does not reliably predict which patients will develop adrenal crisis.
For example, a patient experiencing complications of chronic steroid therapy e. Patients who are at high risk for HPAA suppression i. Preoperative evaluation may be helpful for patients on chronic steroid therapy who do not fall into either of the above categories, as stress-dose steroids can be safely withheld with proof of non-suppressed HPAA. When preoperative evaluation is clinically warranted, the short ACTH stimulation test is the test of choice for assessing the integrity of the HPAA and its function.
Patients with normal response to administration of cosyntropin do not require further evaluation or perioperative glucocorticoid treatment. Other diagnostic methods e.
Free cortisol, not the protein-bound fraction, is responsible for the physiologic effects of cortisol. A recent study by Hamrahian et al. The diagnostic value of free cortisol levels, however, is not definitively proven, and the test itself is also not yet widely available. An additional approach to management of the patient presenting for surgery on chronic steroids is to assess the anticipated surgical stress to determine the appropriate perioperative stress dose table 2.
If the estimated surgical stress requirement does not exceed the maintenance dose of exogenous steroids, stress-dose steroid administration is not warranted during the perioperative period unless the patient exhibits signs of adrenal suppression e. So the practical question remains: Which chronic steroid-treated patients require perioperative stress-dose steroids? Our approach involves categorizing patients into four groups based on the current available evidence:.
Patients who have diagnosed secondary adrenal insufficiency as demonstrated by the short acting ACTH test. These patients will require perioperative stress-dose steroids with dosing based on surgical stress risk table 2.
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 table 2. Perioperative stress-dose steroids are not required unless they exhibit signs of HPAA suppression. Patients at intermediate risk of HPAA suppression, including any patient on chronic steroid therapy who does not fall into one of the above categories.
If time permits, consider referring these patients for preoperative testing to determine their HPAA integrity. It is reasonable, for example, to withhold glucocorticoids if the patient is otherwise healthy and stable preoperatively without signs or symptoms of Cushing disease, with a low threshold for administration of a rescue dose of steroids in the event of unexplained intra- or postoperative hypotension.
Hydrocortisone is the drug of choice for stress and rescue dose steroid coverage. For example, if hydrocortisone dosages more than mg are required, it is prudent to consider switching to methylprednisolone, because this drug has a higher glucocorticoid to mineralocorticoid activity ratio.
Patients on chronic steroid therapy should receive their usual preoperative dose of steroids on the day of surgery. However, existing evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected, or even confirmed, secondary adrenal insufficiency is inadequate to fully support or refute this practice. If HPAA suppression is a clinical concern, perioperative stress-dose steroid administration appears to carry minimal risk compared to the risk of adrenal crisis.
However, the lack of class A and B evidence makes it controversial as to whether the administration of perioperative stress-dose steroids is the standard of care, even for patients with known HPAA suppression. The paucity of evidence highlighted by our examination of the available literature should serve as a call for more adequately powered studies comparing different strategies for perioperative steroid management that can generate robust, high-quality data.
Until such time that class A and B evidence is available for determining an agreed-upon standard of care, we support this practical approach to the perioperative management of patients on chronic steroid therapy presenting for surgery based on our review of the currently available evidence. The authors acknowledge Karen L. The authors also acknowledge the insightful comments of endocrinologists Pouneh Fazeli, M. Sign In or Create an Account.
Search Dropdown Menu. Advanced Search. Sign In. Skip Nav Destination Article Navigation. Close mobile search navigation Article navigation. Volume , Issue 1. Previous Article Next Article. Hypothalamic-Pituitary-Adrenal Axis Suppression.
Historical Perspectives. Current Evidence. Our Approach. Research Support. Competing Interests. Article Navigation. Education July Generally, cortisol levels return to baseline within 48 to 72 hours following the procedure. Thus, in patients receiving supplemental dosing, an additional postoperative 24 hours of coverage for moderate surgery and 48 to 72 hours for major surgery may be reasonable.
Recovery of normal adrenal function following steroid discontinuation has been documented to require as short as a few days up to 9 months, with the time course of recovery a function of the dose and duration of prior therapy. It has been suggested that patients who discontinued their steroids within 3 months of surgery should be assumed to have adrenal suppression, and be treated as such, whereas the remaining patients should simply have additional monitoring for hemodynamic compromise.
January 14, Objective: To conduct a risk-benefit analysis using a meta-analysis, to compare complication rates and clinical advantages associated with the use of high dose methylprednisolone in surgical patients. Methods: Randomised controlled trials of high dose methylprednisolone in elective and trauma surgery were systematically searched for in various literature databases.
Outcome data on adverse effects, postoperative pain and hospital stay were extracted and statistically pooled in fixed-effects meta-analyses.
All rights reserved. J H is a year-old woman scheduled to undergo an exploratory laparotomy with liver laceration repair and splenectomy following a motor vehicle collision. She has been taking 20 mg prednisone daily for the past 5 years for rheumatoid arthritis, and the surgical team inquires about the need for supplemental perioperative steroids.
Patients undergoing a surgical procedure or responding to stress, trauma, or an acute illness will exhibit an increase in adrenal cortisol production up to 6-fold normal levels. However, in patients on chronic exogenous steroid therapy, atrophy of the hypothalamicpituitary-adrenal HPA axis may occur through feedback inhibition, leading to an inability to respond to stress.
It has historically been believed that patients receiving long-term corticosteroids require supplemental, perioperative doses, and that failure to provide such coverage in secondary adrenal insufficiency may lead to an adrenal crisis characterized by hypotension and cardiovascular collapse.
Currently, however, minimal evidence exists regarding optimal type, dose, and duration of supplemental steroids, if any, that should be recommended perioperatively. Given the known detrimental side effects of corticosteroids, including hyperglycemia, delayed wound healing, water retention, hypertension, and neuropsychiatric complications, use of the lowest possible doses is warranted.
The onset of adrenal suppression can occur as early as 1 week after commencing therapy, and usually requires doses of 10 mg of prednisone equivalent or greater. For patients unable to take oral steroids perioperatively, divided doses of hydrocortisone every 6 to 8 hours is appropriate.
Generally, cortisol levels return to baseline within 48 to 72 hours following the procedure. Thus, in patients receiving supplemental dosing, an additional postoperative 24 hours of coverage for moderate surgery and 48 to 72 hours for major surgery may be reasonable. Recovery of normal adrenal function following steroid discontinuation has been documented to require as short as a few days up to 9 months, with the time course of recovery a function of the dose and duration of prior therapy.
It has been suggested that patients who discontinued their steroids within 3 months of surgery should be assumed to have adrenal suppression, and be treated as such, whereas the remaining patients should simply have additional monitoring for hemodynamic compromise.
January 14, Case J H is a year-old woman scheduled to undergo an exploratory laparotomy with liver laceration repair and splenectomy following a motor vehicle collision.
Steroid medications, such as Prednisone®, should be continued both during and after surgery. Most likely, your surgeon will give you additional doses at the. Background: A single preoperative high dose of methylprednisolone (15 to 30 mg/kg) has been advocated in surgery, because it may inhibit the surgical stress. It has been suggested that patients who discontinued their steroids within 3 months of surgery should be assumed to have adrenal suppression. Background: A single preoperative high dose of methylprednisolone (15 to 30 mg/kg) has been advocated in surgery, because it may inhibit the surgical stress. In a recent observational analysis, approximately 3% of the general surgical population received preoperative steroids, which were associated with a 2- to Endoscopic assessment [ Time Frame: 4 weeks, 3 months, 6 months ] The Peri-Operative Sinus Endoscopy POSE scoring system total score will be used to assess the condition of the patients' sinus cavities and the Lindholdt scale will be used to provide objective measures of polyp recurrence size based on the percent obstruction of the nasal cavity and obstruction based on anatomic location. This site uses cookies. Preoperative evaluation may be helpful for patients on chronic steroid therapy who do not fall into either of the above categories, as stress-dose steroids can be safely withheld with proof of non-suppressed HPAA. Actual Primary Completion Date :. The authors acknowledge Karen L.Figure 1 was enhanced by Annemarie B. Johnson, C. Melanie M. Liu, Andrea B. Reidy, Siavosh Saatee, Charles D. CHRONIC steroid therapy is a cornerstone treatment for many common conditions, including inflammatory bowel disease, rheumatologic disease, reactive airway disease, and immunosuppression for transplant recipients.
Patients on chronic steroid therapy may develop secondary adrenal insufficiency that can manifest as full-blown adrenal crisis in the perioperative period. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative stress-dose steroids to mitigate this rare but potentially fatal complication of chronic steroid use.
Unfortunately, this decision is not always clear-cut, because even the recommendations found in major textbooks are confusing, inconsistent, and lacking in class A and B evidence table 1. Posner, Ph.
It is unclear whether this paucity of claims is due to underdiagnosis of adrenal crisis or overtreatment of perioperative patients with steroids. We now review and evaluate the current data on the use of perioperative stress-dose steroids and propose approaches to administration and dosing.
Acute physiologic or psychologic stress activates the hypothalamic-pituitary-adrenal axis HPAA. The hypothalamus produces corticotropin-releasing hormone CRH , which stimulates production of adrenocorticotrophic hormone ACTH in the anterior pituitary, which in turn signals cortisol production in the adrenal glands.
Cortisol has a number of roles within the body, including stimulation of gluconeogenesis, catecholamine production, and activation of antistress and antiinflammatory pathways. Transient increases in cortisol secretion are seen in response to stress, such as illness or surgery. Functional anatomy of hypothalamic-pituitary-adrenal axis. This process is known as secondary adrenal insufficiency.
Unlike in primary adrenal insufficiency, the renin-angiotension-aldosterone system remains intact, and there is no mineralocorticoid deficiency. Inadequate cortisol production may predispose to vasodilatation and hypotension. The clinical picture is one of severe, persistent hypotension that is poorly responsive to fluid and vasopressor therapy.
Perioperative adrenal crisis can be life-threatening and requires prompt recognition and treatment with stress-dose steroids in addition to supportive care with fluid and vasopressor administration. Nevertheless, most agree that HPAA suppression does not continue beyond 1 yr after cessation of exogenous steroid therapy with the possible exception of patients receiving intraarticular glucocorticoid injections, for whom the time course of HPAA suppression is variable, depending on the frequency and dose of injections, and not well studied.
In , cortisone was first commercially produced for the treatment of primary adrenal insufficiency and shortly thereafter was being used as an antiinflammatory and immunosuppressant.
Nevertheless, these two case reports form the basis for much of the current perioperative management of patients with suspected HPAA suppression. Since these sentinel articles, there has been a growing body of literature and debate about the management of patients on chronic steroids who present for surgery. As a whole, the literature on administration of perioperative stress-dose steroids is devoid of class A or B levels of evidence and is complicated by a lack of consistency in patient selection, surgery and anesthesia type, clinical outcome, and steroid timing and dose.
Randomized double-blinded, placebo-controlled trials addressing this topic are few in number and insufficiently powered most involve 20 or fewer patients. Kehlet and Binder 11 published perhaps the most robust data on stress-dose steroids.
Plasma cortisol levels and vitals were followed. Unexplained hypotension defined as systolic blood pressure less than 80 mmHg not due to sepsis, anaphylaxis, or bleeding was found in 7 of 18 hypotensive patients. Additionally, patients who had low plasma cortisol levels before surgery were not significantly more likely to have hypotension.
Moreover, the method used to measure cortisol levels in this study is a fluorometric assay rarely used today, which further calls into question the applicability of these findings. In , Glowniak and Loriaux 12 studied 18 male patients taking prednisone for at least 2 months for various conditions with baseline secondary adrenal insufficiency as determined by cosyntropin study also known as the short ACTH stimulation test.
Patients were randomized to receive stress-dose steroid injections mg of cortisol in normal saline based on the Salem et al.
The authors concluded that patients with secondary adrenal insufficiency as a result of chronic steroid therapy do not experience hypotension in the absence of stress-dose steroid administration and can be maintained on their usual daily dose of steroids in the perioperative period. Thomason et al. Patients were randomized to receive stress-dose steroids versus placebo. Each patient required at least two operations and thus served as their own control. Serum ACTH levels were drawn pre- and postoperatively, and blood pressure was measured at set intervals throughout.
No significant differences in blood pressure or ACTH measurements were found between groups. The authors concluded that patients on chronic steroids do not require stress-dose steroids before undergoing gingival surgery.
Additionally, measurement of random plasma ACTH levels as an indicator of adrenal insufficiency is neither a standard nor valid method of assessing adrenocortical function and further decreases the applicability of the study findings.
Further complicating this muddied picture is the retraction of a Cochrane review in 16 that had concluded, largely based on the articles by Glowniak and Loriaux 12 and Thomason et al. Chronic steroid therapy is well known to be associated with risk of immunosuppression, impaired wound healing, hyperglycemia, and psychologic disturbances in the postoperative period.
Elevated circulating levels of glucocorticoids are associated with a range of psychiatric symptoms including acute psychosis. The authors concluded that stress-dose steroids increased the risk of hyperglycemia without apparent clinical benefit.
Recent data suggest that stress-dose steroids may not be necessary, even in patients with confirmed preoperative secondary HPAA suppression. Marik and Varon 17 suggest that most patients receiving chronic steroid therapy do not need preoperative evaluation of their adrenocortical function unless there is clinical reason to believe that it might affect perioperative management, as this testing does not reliably predict which patients will develop adrenal crisis.
For example, a patient experiencing complications of chronic steroid therapy e. Patients who are at high risk for HPAA suppression i. Preoperative evaluation may be helpful for patients on chronic steroid therapy who do not fall into either of the above categories, as stress-dose steroids can be safely withheld with proof of non-suppressed HPAA.
When preoperative evaluation is clinically warranted, the short ACTH stimulation test is the test of choice for assessing the integrity of the HPAA and its function.
Patients with normal response to administration of cosyntropin do not require further evaluation or perioperative glucocorticoid treatment. Other diagnostic methods e. Free cortisol, not the protein-bound fraction, is responsible for the physiologic effects of cortisol. A recent study by Hamrahian et al. The diagnostic value of free cortisol levels, however, is not definitively proven, and the test itself is also not yet widely available.
An additional approach to management of the patient presenting for surgery on chronic steroids is to assess the anticipated surgical stress to determine the appropriate perioperative stress dose table 2. If the estimated surgical stress requirement does not exceed the maintenance dose of exogenous steroids, stress-dose steroid administration is not warranted during the perioperative period unless the patient exhibits signs of adrenal suppression e.
So the practical question remains: Which chronic steroid-treated patients require perioperative stress-dose steroids? Our approach involves categorizing patients into four groups based on the current available evidence:. Patients who have diagnosed secondary adrenal insufficiency as demonstrated by the short acting ACTH test. These patients will require perioperative stress-dose steroids with dosing based on surgical stress risk table 2.
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 table 2. Perioperative stress-dose steroids are not required unless they exhibit signs of HPAA suppression. Patients at intermediate risk of HPAA suppression, including any patient on chronic steroid therapy who does not fall into one of the above categories.
If time permits, consider referring these patients for preoperative testing to determine their HPAA integrity. It is reasonable, for example, to withhold glucocorticoids if the patient is otherwise healthy and stable preoperatively without signs or symptoms of Cushing disease, with a low threshold for administration of a rescue dose of steroids in the event of unexplained intra- or postoperative hypotension. Hydrocortisone is the drug of choice for stress and rescue dose steroid coverage.
For example, if hydrocortisone dosages more than mg are required, it is prudent to consider switching to methylprednisolone, because this drug has a higher glucocorticoid to mineralocorticoid activity ratio. Patients on chronic steroid therapy should receive their usual preoperative dose of steroids on the day of surgery. However, existing evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected, or even confirmed, secondary adrenal insufficiency is inadequate to fully support or refute this practice.
If HPAA suppression is a clinical concern, perioperative stress-dose steroid administration appears to carry minimal risk compared to the risk of adrenal crisis. However, the lack of class A and B evidence makes it controversial as to whether the administration of perioperative stress-dose steroids is the standard of care, even for patients with known HPAA suppression.
The paucity of evidence highlighted by our examination of the available literature should serve as a call for more adequately powered studies comparing different strategies for perioperative steroid management that can generate robust, high-quality data. Until such time that class A and B evidence is available for determining an agreed-upon standard of care, we support this practical approach to the perioperative management of patients on chronic steroid therapy presenting for surgery based on our review of the currently available evidence.
The authors acknowledge Karen L. The authors also acknowledge the insightful comments of endocrinologists Pouneh Fazeli, M. Sign In or Create an Account. Search Dropdown Menu. Advanced Search. Sign In. Skip Nav Destination Article Navigation. Close mobile search navigation Article navigation. Volume , Issue 1. Previous Article Next Article. Hypothalamic-Pituitary-Adrenal Axis Suppression.
Historical Perspectives. Current Evidence. Our Approach. Research Support. Competing Interests. Article Navigation. Education July Liu, M. Address correspondence to Dr. Box , Houston, Texas Information on purchasing reprints may be found at www.
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