Are steroids safe to use before anesthesia?

From the Guidelines

Steroids are safe before anesthesia, but patients on long-term steroid therapy should inform their anesthesiologist and may require supplemental "stress-dose" steroids to prevent adrenal insufficiency, as recommended by the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. When considering steroid use before anesthesia, it's essential to assess the patient's individual risk of adrenal insufficiency, which can be caused by long-term glucocorticoid therapy, including prednisolone ≥ 5 mg per day in adults or hydrocortisone-equivalent dose of 10–15 mg.m2 per day in children 1.

• Key considerations for patients on steroid therapy include:
  • Informing the anesthesiologist about steroid medications to determine the need for supplemental steroids during the perioperative period
  • Continuing regular steroid doses on the day of surgery for patients on long-term therapy
  • Administering hydrocortisone 100 mg by intravenous injection at induction of anesthesia, followed by a continuous infusion of hydrocortisone at 200 mg.24 h-1, until the patient can take double their usual oral glucocorticoid dose by mouth, as recommended by the guidelines 1
• The anesthesia team should monitor patients closely for potential complications, such as:
  • Blood glucose level changes
  • Wound healing issues
  • Blood pressure fluctuations It's crucial to collaborate with the patient's endocrinologist when planning scheduled surgery and caring for postoperative patients to ensure the best possible outcomes 1.

From the FDA Drug Label

Infection with any pathogen (viral, bacterial, fungal, protozoan or helminthic) in any location of the body may be associated with the use of corticosteroids alone or in combination with other immunosuppressive agents. Patients who are on corticosteroids are more susceptible to infections than are healthy individuals.

The use of steroids before anesthesia may increase the risk of infection. Corticosteroids can mask some signs of current infection, and patients on corticosteroids are more susceptible to infections than healthy individuals 2. It is recommended to use caution when administering corticosteroids to patients who will be undergoing anesthesia, as the risk of infection may be increased. Key considerations include:

• Infection risk: Corticosteroids may increase the risk of infection, which can be severe or fatal.
• Masking infection signs: Corticosteroids can mask some signs of current infection, making it difficult to diagnose and treat infections promptly.
• Patient susceptibility: Patients on corticosteroids are more susceptible to infections than healthy individuals.

From the Research

Steroid Safety Before Anesthesia

• The use of steroids before anesthesia is a topic of discussion among medical professionals, with some studies suggesting that patients receiving chronic steroid therapy may require additional steroid doses during the perioperative period to prevent adrenal insufficiency 3, 4, 5.
• Adrenal insufficiency can lead to major complications, such as full-blown adrenal crisis, during the perioperative period 3.
• However, there is no universally accepted regimen for glucocorticoid supplementation therapy, and the optimal dose and duration of supplementation have not been established 4.
• Some studies recommend the use of lower doses of glucocorticoids during surgical and medical stress, rather than the high doses traditionally used 4, 6.
• The importance of monitoring patients on long-term oral corticosteroids for adverse effects, such as weight gain, osteoporosis, and hypertension, is also highlighted 7.
• Anesthesia providers must be aware of the need for corticosteroid replacement in patients with primary adrenal insufficiency or those who have adrenal insufficiency resulting from long-term corticosteroid therapy 5.

Key Considerations

• Patients with adrenal insufficiency require additional glucocorticoid doses during surgery or medical illness 4.
• The hypothalamic-pituitary-adrenal axis and the molecular mechanism of action of its biologically active components should be considered when determining the need for steroid supplementation 6.
• Clinical experience and expert opinion suggest that the optimal dose and duration of supplementation therapy have not been established, and that clinical judgement is essential in managing patients with adrenal insufficiency 4, 5.

Implications for Anesthesia Providers

• Anesthesia providers must be aware of the potential risks and benefits of steroid therapy in patients undergoing surgery 3, 5.
• They should be knowledgeable about the need for corticosteroid replacement in patients with adrenal insufficiency and the appropriate dosing regimens 4, 5.
• Close monitoring of patients on long-term oral corticosteroids is essential to prevent adverse effects 7.