What are the recommendations for managing corticosteroids in a patient with adrenal insufficiency during carpal tunnel surgery?

From the Guidelines

For patients with adrenal insufficiency undergoing carpal tunnel surgery, perioperative stress-dose corticosteroid supplementation with hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24h, is recommended. This approach is based on the most recent guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK, as outlined in the study by Woodcock et al. 1. The guidelines emphasize the importance of not interrupting physiological replacement therapy and increasing the daily dose at times of physiological stress, such as surgery.

Key Considerations

• The patient's regular morning dose of corticosteroids should be taken on the day of surgery if the procedure is scheduled later in the day.
• Maintain adequate intravenous fluids during surgery and monitor for signs of adrenal crisis, including hypotension, tachycardia, nausea, and confusion.
• After surgery, the patient should resume their regular corticosteroid regimen once they are able to take oral medications, with the option to double the regular oral replacement dose of hydrocortisone for 48 hours or up to a week following major surgery, as recommended by the guidelines 1.

Rationale

The rationale for this approach is that patients with adrenal insufficiency cannot mount an appropriate cortisol stress response during surgery, which could lead to life-threatening adrenal crisis. Even though carpal tunnel surgery is relatively minor, any surgical procedure represents physiologic stress that requires increased cortisol production. The guidelines provide a clear framework for managing glucocorticoids during the peri-operative period, and the recommended doses for intra- and postoperative steroid cover are outlined in Table 1 of the study by Woodcock et al. 1.

Management

• Intra-operative steroid replacement: hydrocortisone 100 mg intravenously on induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg/24h.
• Postoperative steroid replacement: hydrocortisone 200 mg/24h by i.v. infusion while nil by mouth or for patients with postoperative vomiting, or hydrocortisone 50 mg every 6 hours by i.m. injection.
• Resume enteral – double hydrocortisone doses for 48 hours or for up to a week following major surgery, as recommended by the guidelines 1.

From the Research

Management of Corticosteroids in Adrenal Insufficiency

• Patients with adrenal insufficiency require increased hydrocortisone cover during major stress, such as surgery, to avoid a life-threatening adrenal crisis 2.
• The most appropriate mode of hydrocortisone delivery in patients with adrenal insufficiency exposed to major stress is continuous intravenous infusion, which achieves median cortisol concentrations in the range observed during major stress 2.
• Linear pharmacokinetic modeling identifies continuous intravenous infusion of 200 mg hydrocortisone over 24 hours, preceded by an initial bolus of 50-100 mg hydrocortisone, as best suited for maintaining cortisol concentrations in the required range 2.

Prevention and Treatment of Adrenal Crisis

• Adrenal crisis is an acute life-threatening emergency that can be prevented and treated with prompt recognition and administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities 3, 4.
• Patient education is crucial in preventing adrenal crisis, and patients should be educated on stress dosing and parenteral glucocorticoid administration 3, 4.
• Patients with adrenal insufficiency should carry a steroid dependency alert card and wear a medical alert bracelet or similar identification 3.

Recommendations for Management of Adrenal Insufficiency

• Chronic replacement therapy with glucocorticoids and, in primary adrenal insufficiency, mineralocorticoids requires careful monitoring 5.
• Future studies will have to explore the potential of dehydroepiandrosterone replacement and modified delayed-release hydrocortisone to improve the prospects of patients with adrenal insufficiency 5.
• The benefit of hormone replacement therapy is evident, but long-term adverse effects may arise due to the non-physiological GC doses and treatment regimens used 6.
• European Reference Networks on rare endocrine conditions aim at harmonizing treatment and ensuring access to specialized patient care for individual case-by-case treatment decisions 6.

Carpal Tunnel Surgery Considerations

• Patients with adrenal insufficiency undergoing carpal tunnel surgery should receive stress dose hydrocortisone administration to prevent adrenal crisis 2, 4.
• The anesthesiologist and surgeon should be aware of the patient's adrenal insufficiency and take necessary precautions to prevent adrenal crisis during surgery 3, 4.