Is hydrocortisone (cortisol) supplementation required for patients already on hydrocortisone (cortisol) undergoing procedures under local anesthesia?

Hydrocortisone Supplementation Under Local Anesthesia

Hydrocortisone supplementation is NOT required for patients already on hydrocortisone therapy who are undergoing procedures under local anesthesia. 1

Rationale for No Supplementation

The 2020 guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK provide clear recommendations regarding glucocorticoid supplementation during perioperative periods. These guidelines specifically address different types of surgical procedures and anesthetic techniques, but do not recommend supplemental hydrocortisone for procedures under local anesthesia 1.

The guidelines focus on supplementation for:

• Surgery under general or regional anesthesia
• Bowel procedures requiring laxatives/enemas
• Labor and delivery
• Major and intermediate surgery

Notably absent are recommendations for supplementation during procedures performed under local anesthesia, indicating that such supplementation is not considered necessary.

Physiological Basis

The rationale for this recommendation is based on the physiological stress response:

• Major surgical procedures trigger a significant stress response with a five-fold increase in cortisol production (approximately 100 mg/day) 1
• Local anesthesia procedures induce minimal physiological stress and do not significantly activate the hypothalamic-pituitary-adrenal axis
• Patients already on hydrocortisone replacement are receiving their baseline physiological requirements

Clinical Algorithm for Hydrocortisone Management

1. For procedures under local anesthesia:

   • Continue regular hydrocortisone dosing schedule
   • No additional supplementation required
   • Ensure patient takes their regular morning dose if procedure is scheduled in the morning

2. For procedures under general or regional anesthesia:

   • Hydrocortisone 100 mg IV at induction
   • Followed by continuous infusion of 200 mg/24h
   • Postoperatively double the usual oral dose for 48 hours 1

3. For intermediate procedures:

   • Hydrocortisone 100 mg IV at induction
   • Double regular dose for 48 hours postoperatively 1

Important Considerations and Pitfalls

• Common pitfall: Over-supplementation of glucocorticoids for minor procedures, which can lead to unnecessary side effects including hyperglycemia and hypokalemia 2

• Warning signs to monitor: Despite the recommendation against routine supplementation, be alert for signs of adrenal insufficiency during or after the procedure:

  • Unexplained hypotension
  • Nausea/vomiting
  • Confusion
  • Hypoglycemia

• Special circumstances: If the local anesthesia procedure becomes prolonged or complicated, or if the patient shows signs of significant stress (pain, anxiety), consider administering supplemental hydrocortisone (50-100 mg) 3

Evidence Quality Assessment

The recommendation is based primarily on the 2020 guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK 1, which represent the most recent and comprehensive guidance on perioperative glucocorticoid management. These guidelines are considered high quality as they were developed by multiple prestigious medical societies.

While some older research has suggested routine stress dosing for all procedures 4, more recent evidence indicates that this approach is unnecessary for minor procedures, particularly those under local anesthesia 5.

The focus on minimizing unnecessary glucocorticoid supplementation aligns with the goal of preventing potential adverse effects while ensuring adequate coverage for truly stressful procedures.