From the Guidelines
Patients with primary or secondary adrenal insufficiency, or those taking chronic steroid therapy at doses of 5 mg or greater of prednisolone (or equivalent) for more than 1 month, require stress dose steroids during the perioperative period to prevent adrenal crisis. The recommended regimen involves hydrocortisone 100 mg intravenously at the start of surgery, followed by a continuous infusion of 200 mg/24 h 1. For patients undergoing major surgery, the infusion should be continued until the patient is able to resume their regular oral replacement dose, which should be doubled for 48 hours to 1 week postoperatively 1. The dose and duration of stress steroids should be tailored to the degree of surgical stress, with higher doses and longer durations for more invasive procedures 1. It is essential to collaborate with the patient's endocrinologist and to educate the patient on "Sick Day Rules" to prevent adrenal crisis during periods of physiological stress 1. The goal of stress dose steroids is to prevent morbidity, mortality, and to maintain quality of life by avoiding adrenal crisis, which can be characterized by hypotension, electrolyte abnormalities, and even cardiovascular collapse 1.
Some key points to consider when administering stress dose steroids include:
- Patients with primary adrenal insufficiency, secondary adrenal insufficiency, or those taking chronic steroid therapy are at risk of adrenal crisis during the perioperative period 1
- The recommended regimen involves hydrocortisone 100 mg intravenously at the start of surgery, followed by a continuous infusion of 200 mg/24 h 1
- The dose and duration of stress steroids should be tailored to the degree of surgical stress, with higher doses and longer durations for more invasive procedures 1
- Patients should be educated on "Sick Day Rules" to prevent adrenal crisis during periods of physiological stress 1
- Collaboration with the patient's endocrinologist is essential to ensure optimal management of adrenal insufficiency during the perioperative period 1
From the FDA Drug Label
Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy subjected to any unusual stress before, during, and after the stressful situation
- Patients on corticosteroid therapy who are subjected to any unusual stress, such as surgery, require an increased dosage of rapidly acting corticosteroids before, during, and after the stressful situation 2, 3, 4.
- This is to prevent adrenal insufficiency due to the suppression of the hypothalamic-pituitary-adrenal (HPA) axis.
- The exact dosage and duration of the stress dose will depend on the individual patient's situation and the specific corticosteroid being used.
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 5
- Patients on maintenance doses of glucocorticoids, although the evidence is unclear on whether supplemental perioperative steroids are required 5, 6
- Patients with a history of adrenal insufficiency or those who have undergone adrenal surgery 7
Diagnosis and Treatment of Adrenal Insufficiency
Adrenal insufficiency can be diagnosed using various tests, including the adrenocorticotropic hormone (ACTH) stimulation test 8
- 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 8
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 9
- 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 9