From the Guidelines
Stress dose steroids are needed for patients with adrenal insufficiency, including those with primary and secondary adrenal insufficiency, and those taking chronic steroid therapy, to prevent adrenal crisis during surgery. The typical regimen involves hydrocortisone 100 mg IV immediately before surgery, followed by a continuous infusion of hydrocortisone 200 mg/24h, as recommended by the guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. For patients undergoing major surgery, the guidelines recommend hydrocortisone 100 mg IV at induction, followed by a continuous infusion of hydrocortisone 200 mg/24h, and resuming enteral glucocorticoid at double the pre-surgical therapeutic dose for 48 h or up to a week following major surgery 1. The degree and duration of supplementation should be tailored to the severity of surgical stress and the patient's baseline steroid requirements, and it is essential to collaborate with the patient's endocrinologist when planning scheduled surgery and when caring for postoperative cases, especially for patients with multiple risk factors 1. Some key points to consider include:
- Patients with primary and secondary adrenal insufficiency are at significant risk of adrenal crisis and must be given stress doses of hydrocortisone during the peri-operative period 1.
- Daily doses of prednisolone of 5 mg or greater in adults may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more, and these patients may require perioperative steroid supplementation 1.
- The guidelines provide recommended doses for intra- and postoperative steroid cover in adults with primary and secondary adrenal insufficiency, including hydrocortisone 100 mg IV at induction, followed by a continuous infusion of hydrocortisone 200 mg/24h 1. It is crucial to prioritize the patient's safety and well-being by providing adequate steroid supplementation during the peri-operative period, as adrenal crisis can be life-threatening if not promptly treated 1.
From the FDA Drug Label
Patients should be observed closely for signs that might require dosage adjustment, including changes in clinical status resulting from remissions or exacerbations of the disease, individual drug responsiveness, and the effect of stress (e.g., surgery, infection, trauma). During stress it may be necessary to increase dosage temporarily.
You need to stress dose steroids for surgery in patients who are already on steroid therapy, as the stress of surgery may require a temporary increase in dosage. 2
From the Research
Patients Requiring Stress Dose Steroids for Surgery
The following patients may require stress dose steroids for surgery:
- Patients with adrenal insufficiency, as they may be at risk of adrenal crisis during surgery 3
- Patients on maintenance doses of glucocorticoids, although the evidence is unclear on whether supplemental perioperative steroids are required 3, 4
- Patients with a history of adrenal insufficiency or those who have undergone adrenal surgery 5
Diagnosis and Treatment of Adrenal Insufficiency
Adrenal insufficiency can be diagnosed using various tests, including the adrenocorticotropic hormone (ACTH) stimulation test 6
- The low-dose ACTH stimulation test has been shown to be more sensitive and specific than the high-dose test
- Administration of high-dose corticosteroids may not be beneficial and may even be harmful, while administration of low-dose corticosteroids for a longer duration may decrease mortality 6
Glucocorticoid Replacement Dose
The recommended daily glucocorticoid replacement dose for patients with adrenal insufficiency is 15 to 25 mg of hydrocortisone (HC) in divided doses 7
- However, a daily glucocorticoid replacement dose of 4.3 to 26 mg/d HC with a midpoint of 15 mg/d is predicted from current measurements of daily cortisol production rates and oral HC bioavailability
- A titration method for determination of the individual patient's daily glucocorticoid replacement dose may be necessary to avoid glucocorticoid overtreatment and associated long-term adverse outcomes 7