Perioperative steroids

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