Are corticosteroids (steroids) contraindicated preoperatively?

From the Guidelines

Corticosteroids are not contraindicated preoperatively, but their use requires careful consideration to prevent adrenal insufficiency and minimize potential complications. Patients on chronic steroid therapy, such as prednisone, dexamethasone, or methylprednisolone, should continue their regular doses and may need supplemental "stress doses" on the day of surgery, as recommended by the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. For patients taking more than 5 mg of prednisone daily (or equivalent) for longer than 2-3 weeks, a typical stress dose would be hydrocortisone 100 mg IV before surgery, followed by 50 mg every 8 hours for 24 hours, then tapering back to their maintenance dose, as suggested by Coccolini et al. 1.

Key Considerations

• Chronic steroid use suppresses the hypothalamic-pituitary-adrenal axis, reducing the body's ability to produce cortisol in response to the stress of surgery 1.
• Short-term steroid use immediately before surgery should be evaluated case by case, as steroids can potentially impair wound healing and increase infection risk 1.
• The surgeon and anesthesiologist should always be informed about any steroid use, current or recent, to make appropriate perioperative management decisions 1.
• Hydrocortisone is the drug of choice for stress and rescue dose steroid coverage, with a recommended dose of 100 mg IV before surgery, followed by 50 mg every 8 hours for 24 hours 1.

Potential Complications

• Adrenal insufficiency: patients on chronic steroid therapy may require supplemental "stress doses" to prevent adrenal insufficiency 1.
• Impaired wound healing: short-term steroid use immediately before surgery may increase the risk of impaired wound healing 1.
• Increased infection risk: short-term steroid use immediately before surgery may increase the risk of infection 1.

Recommendations

• Patients on chronic steroid therapy should continue their regular doses and may need supplemental "stress doses" on the day of surgery 1.
• Short-term steroid use immediately before surgery should be evaluated case by case, considering the potential risks and benefits 1.
• The surgeon and anesthesiologist should always be informed about any steroid use, current or recent, to make appropriate perioperative management decisions 1.

From the Research

Corticosteroids Preoperatively

• The use of corticosteroids preoperatively is a topic of discussion, with some studies suggesting that they may not be necessary for all patients 2.
• Patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids, as long as they continue to receive their usual daily dose of corticosteroid 2.
• However, patients receiving physiologic replacement doses of corticosteroids due to primary disease of the hypothalamic-pituitary-adrenal axis require supplemental doses of corticosteroids in the perioperative period 2.

Adrenal Insufficiency

• Adrenal insufficiency is a concern in patients who have been taking corticosteroids long-term, as it can lead to hypotension and adrenal crisis 3, 4.
• However, studies have shown that the risk of adrenal insufficiency can be managed with careful monitoring and supplementation of corticosteroids as needed 4, 5.

Perioperative Management

• The perioperative management of patients taking corticosteroids requires careful consideration of the potential risks and benefits of supplemental corticosteroids 6, 5.
• A single dose of dexamethasone may not increase the risk for postoperative infection, but it can produce a mild increase in glucose levels among participants without diabetes during the first 12 hours after surgery 6.
• The administration of stress-dose glucocorticoids should be based on the invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis, with the goal of supplementing glucocorticoids at the same level as that of normal physiological response to surgical stress 5.

Key Findings

• Patients with primary adrenal insufficiency or those taking long-term corticosteroids may require supplemental doses of corticosteroids in the perioperative period 2, 3.
• The use of stress-dose corticosteroids should be individualized based on the patient's specific needs and the type of surgery being performed 4, 5.
• Further studies are needed to determine the optimal dose and duration of corticosteroid supplementation in the perioperative period 6, 5.