Are steroids safe to use in postoperative (after surgery) patients?

Steroids in Postoperative Patients: Safety Considerations

Steroids are generally safe in postoperative patients when appropriately managed, but require specific protocols based on the patient's steroid history and surgical complexity to prevent adrenal insufficiency while minimizing complications.

Patient Categories Requiring Special Steroid Management

1. Patients with Adrenal Insufficiency

Patients with primary or secondary adrenal insufficiency require specific steroid supplementation during the perioperative period 1:

• Major surgery:

  • Intraoperative: Hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24h
  • Postoperative: Continue 200 mg/24h IV infusion while NPO, then double oral hydrocortisone doses for 48h or up to a week following major surgery

• Rapid recovery surgery:

  • Resume enteral route with double hydrocortisone doses for 24-48h

2. Patients on Chronic Steroid Therapy

For patients on chronic steroid therapy (≥5 mg prednisolone equivalent for ≥4 weeks) 1:

• Continue usual regimen: Patients should remain on their usual steroid regimen during the perioperative period
• No need for "push-dose": Recent evidence suggests that additional "stress-dose" steroids are not necessary as long as patients continue their usual dosage
• Monitoring: Be vigilant for signs of adrenal insufficiency (hypotension unresponsive to fluids, cognitive dysfunction, malaise)
• Emergency treatment: If adrenal crisis is suspected, administer 100 mg hydrocortisone IV followed by 50 mg q6h 1

Risks of Steroids in Postoperative Patients

High-dose preoperative steroids (>80 mg/day hydrocortisone equivalent) are associated with increased postoperative complications 2:

• Wound healing complications:

  • Increased risk of superficial surgical site infections (odds ratio 1.72)
  • Increased risk of deep surgical site infections (odds ratio 2.35)
  • Increased risk of wound dehiscence (odds ratio 3.34) 3

• Other complications:

  • Sodium and water retention affecting fluid balance
  • Hyperglycemia (particularly in diabetic patients)
  • Increased risk of infection
  • Increased mortality (odds ratio 3.92) 3

Specific Clinical Scenarios

Inflammatory Bowel Disease Surgery

For IBD patients undergoing surgery 1:

• Corticosteroids should be stopped or minimized before elective surgery
• If on steroids during surgery, provide IV hydrocortisone in equivalent dosage (prednisolone 5 mg = hydrocortisone 20 mg)
• No need to increase steroid dosage to cover surgical stress
• Implement standardized steroid-taper protocols postoperatively

Day Case Surgery

For patients with adrenal insufficiency undergoing day case surgery 1:

• Body surface surgery can be performed as day case
• Ensure adequate recovery and absence of nausea/vomiting before discharge
• Instruct patients to return if they feel unwell
• For laparoscopic surgery, consider "23h stay" protocol
• Ensure patients understand "sick day rules" and have injection kits if needed

Algorithm for Perioperative Steroid Management

1. Assess patient's steroid status:

   • Adrenal insufficiency
   • Chronic steroid therapy (≥5 mg prednisolone daily for ≥4 weeks)
   • Recent steroid use (within past year)
   • No steroid history

2. For patients with adrenal insufficiency:

   • Follow specific dosing guidelines based on surgery type (see tables in guidelines) 1
   • Monitor for signs of adrenal crisis

3. For patients on chronic steroids:

   • Continue usual regimen
   • Be aware of increased risk of complications
   • Monitor for signs of adrenal insufficiency

4. For patients with no steroid history:

   • No perioperative steroids needed unless specifically indicated for other reasons

5. Postoperative monitoring:

   • Watch for orthostatic hypotension
   • Monitor mental status changes
   • Check sodium levels if concerned
   • Do not reduce steroid supplementation while patient is pyrexial

Important Caveats

• The short-term use of hydrocortisone supplementation during uncomplicated surgery carries minimal risk 1
• Patients with bronchopulmonary disorders requiring long-term steroid therapy have higher risk of steroid-related complications after surgery 4
• Collaboration with the patient's endocrinologist is recommended when planning scheduled surgery 1
• Patients may carry steroid emergency cards or wear medical alert jewelry - respect their knowledge about their condition 1

Remember that adrenal crisis can be life-threatening, and the risk of providing appropriate steroid coverage is generally less than the risk of adrenal crisis in susceptible patients.