What is the role of corticosteroids (steroids) in surgery?

From the Guidelines

Patients on chronic steroid therapy should continue their usual steroid dose on the day of surgery and may need supplemental steroids to prevent adrenal crisis, with the most recent guidelines suggesting hydrocortisone 100 mg intravenously at induction, followed by a continuous infusion of hydrocortisone 200 mg/24h for major surgeries 1.

Perioperative Steroid Management

The management of patients on chronic steroid therapy undergoing surgery is crucial to prevent adrenal crisis.

• The hypothalamic-pituitary-adrenal axis is suppressed in patients on chronic steroid therapy, making them unable to mount an appropriate stress response during surgery 1.
• The risk of adrenal crisis is higher in patients undergoing major surgeries, and supplemental steroids may be necessary to prevent this complication 1.
• The most recent guidelines suggest that patients on chronic steroid therapy should continue their usual steroid dose on the day of surgery and may need supplemental steroids, with hydrocortisone being the drug of choice for stress and rescue dose steroid coverage 1.

Recommended Doses

The recommended doses for intra- and postoperative steroid cover in adults receiving adrenosuppressive doses of steroids are:

• Hydrocortisone 100 mg intravenously at induction, followed by a continuous infusion of hydrocortisone 200 mg/24h for major surgeries 1.
• For minor procedures, the usual daily steroid dose may be sufficient, while for moderate procedures, hydrocortisone 50-75 mg/day for 1-2 days may be necessary 1.

Monitoring

It is essential to monitor blood pressure, electrolytes, and glucose levels closely during the perioperative period to prevent complications such as hypotension, electrolyte abnormalities, and cardiovascular collapse 1.

Conclusion is not allowed, so the answer will be ended here, but it is essential to consider the most recent guidelines and the patient's individual needs when managing perioperative steroid therapy.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Glucocorticoids, naturally occurring and synthetic, are adrenocortical steroids that are readily absorbed from the gastrointestinal tract. The FDA drug label does not answer the question.

From the Research

Perioperative Steroid Therapy

• The use of perioperative "stress dose" steroids is a topic of debate among anesthesiologists and endocrinologists 2, 3, 4.
• Patients on chronic steroid therapy are at risk of adrenal insufficiency during the perioperative period, which can lead to major complications such as adrenal crisis 2, 5.
• The concept of perioperative "stress dose" steroids is to mitigate this risk by administering additional steroids during the perioperative period 2.
• However, recent studies suggest that the incidence of perioperative adrenal insufficiency in patients receiving chronic glucocorticoid therapy is low, and that withholding perioperative stress steroids may not affect survival or hemodynamic outcomes 3, 4.

Steroid Dosing and Administration

• Current recommendations for perioperative stress dose steroids are based on the duration and dose of maintenance steroids, as well as patient risk of adrenal suppression and surgical complexity and stress 3.
• Some studies suggest that patients on long-term exogenous steroids do not require high-dose perioperative corticosteroids and should instead remain on their baseline maintenance dose 4.
• Additional steroid dosing should be considered on a case-by-case basis, taking into account the individual patient's risk factors and medical history 3, 4.

Adrenal Insufficiency and Steroid Replacement

• Adrenal insufficiency is a rare disease, but its prevalence is increasing, and patients with this condition are at risk of adrenal crisis, usually precipitated by major stress such as severe infection or surgery 5.
• Chronic glucocorticoid replacement therapy is the standard treatment for adrenal insufficiency, but novel strategies such as hydrocortisone infusion pumps and oral modified release hydrocortisone are being developed to replicate the physiological cortisol rhythm 6.
• These new approaches aim to improve patient health and quality of life, but larger studies are needed to understand their effectiveness and potential to replace conventional treatments 6.