Learning objectives

• Recognize the signs and symptoms of a perioperative adrenal crisis
• Be able to treat a perioperative adrenal crisis
• Anesthetic management of a patient on chronic steroid therapy

Definition and mechanisms

• Chronic steroid therapy is used in the treatment of many common conditions (e.g., inflammatory bowel disease, rheumatologic disease, asthma, chronic obstructive pulmonary disease, and immunosuppression for transplant recipients)
• Patients on chronic steroid therapy may develop secondary adrenal insufficiency
  • Patients on chronic steroids may experience HPA axis suppression
  • Result in low CRH and ACTH levels, leading to atrophy of the adrenal zona fasciculata and a decrease in cortisol production = secondary adrenal insufficiency
  • The renin-angiotensin-aldosterone system remains intact
  • No mineralocorticoid deficiency
  • Inadequate cortisol levels may predispose to vasodilation and hypotension
• Secondary adrenal insufficiency can manifest as an adrenal crisis in the perioperative period

Hypothalamic-pituitary-adrenal (HPA) axis

• Acute physiologic or psychologic stress activates the HPA axis
• Hypothalamus produces corticotropin-releasing hormone (CRH)
• CRH stimulates the production of adrenocorticotropic hormone (ACTH) in the anterior pituitary
• ACTH signals cortisol production in the adrenal glands
• Cortisol production is self-regulated via negative feedback loops, leading to decreased production of CRH and ACTH

Roles of cortisol

• Stimulate gluconeogenesis
• Catecholamine production
• Activation of anti-stress and anti-inflammatory pathways
• Maintain cardiac output and contractility via modulation of β-receptor synthesis and function
• Enhance vascular tone via an increased sensitivity to catecholamines

Signs and symptoms

Signs and symptoms of an adrenal crisis in the awake patient may include:

• Altered mental status
• Abdominal pain
• Nausea and vomiting
• Weakness
• Hypotension

These signs and symptoms are largely absent in the anesthetized patient and nonspecific in the postoperative patient → severe, persistent hypotension that is poorly responsive to fluid and vasopressor therapy

Treatment

Perioperative adrenal crisis can be life-threatening and requires prompt recognition and treatment

• Stress-dose steroids 
• Supportive care with fluids and vasopressors

Management

Risk stratification

1. Patients who have been diagnosed with secondary adrenal insufficiency

• Demonstrated by short-acting ACTH test
• Require perioperative stress-dose steroids with dosing based on surgical stress risk

2. Patients at high risk of HPA axis suppression

• Patients treated with a glucocorticoid in doses equivalent to >20 mg/day of prednisone for >3 weeks or who have clinical features of Cushing syndrome
• Perioperative stress-dose steroids with dosing based on surgical stress

3. Patient at low risk of HPA axis suppression

• Patients treated with any dose of glucocorticoid for <3 weeks, morning doses of prednisone ≤5 mg/day, or prednisone 10 mg/day every other day
• Perioperative stress-dose steroids are not required unless these patients exhibit signs of HPA axis suppression

4. Patients at intermediate risk of HPA axis suppression

• Patients on chronic steroid therapy who do not fall into one of the above categories (>5 mg/day but <20 mg/day)
• Refer patients for preoperative testing to determine HPA axis integrity
• Decide whether or not to administer stress-dose steroids based on the patient’s perioperative condition (e.g., hemodynamic status) and surgical risk

Dosing

• Moderate risk surgery: Hydrocortisone 50 mg i.v. q8h x 3 doses
• High-risk surgery: Hydrocortisone 100 mg i.v. q8h x 3 doses

Keep in mind

• Patients on chronic steroids are at risk for an adrenal crisis during periods of stress due to their attenuated ability to mount a cortisol response
• The patient’s risk for an adrenal crisis must be weighed against the risks of unnecessary steroid supplementation

Suggested reading

• Liu MM, Reidy AB, Saatee S, Collard CD. Perioperative Steroid Management: Approaches Based on Current Evidence. Anesthesiology. 2017;127:166-172.