Is it safe to administer a corticosteroid (CS) injection before surgery?

Corticosteroid Injections Before Surgery: Safety Considerations

Corticosteroid injections should be avoided within 3 months before elective surgery due to increased risk of postoperative infections and wound healing complications. 1

Risks of Preoperative Corticosteroid Injections

• Patients undergoing surgery while on corticosteroids have an increased risk of postoperative infectious complications and anastomotic leaks 2
• Intra-articular corticosteroid injections administered within 3 months before joint arthroplasty are associated with a significantly higher risk of periprosthetic joint infection (odds ratio 1.39) 1
• There appears to be both a time and dose-dependent relationship between corticosteroid injections and infection risk, with injections closer to surgery time carrying higher risk 3
• The risk is particularly high when injections are administered within 2-4 weeks of surgery, with injections within 2 weeks showing an odds ratio of 2.89 for postoperative infection 4

Timing Recommendations

• For elective surgeries, corticosteroids should be stopped or dose minimized wherever possible to reduce risk of postoperative complications 2
• Corticosteroid injections should be avoided for at least 3 months preceding joint replacement surgery 2, 1
• For patients who have received an intra-articular corticosteroid injection, it is recommended to delay elective surgery for at least 3 months 1
• For patients who have had hip injections, the risk of periprosthetic joint infection shows a dose-dependent relationship, with each subsequent injection increasing odds of infection 3

Special Considerations for Patients on Chronic Steroids

• Patients on chronic steroids (≥5 mg prednisolone equivalent for 4+ weeks) require special perioperative management 5
• These patients should receive intravenous hydrocortisone in equivalent dosage until they can resume oral prednisolone 2, 5
• Prednisolone 5 mg is equivalent to hydrocortisone 20 mg or methylprednisolone 4 mg 2, 5
• For patients on physiological corticosteroid replacement due to disorders of the hypothalamic pituitary axis, supplementary doses are needed in the perioperative period 2

Monitoring and Management

• After surgery, it's important to avoid inappropriate prolongation of steroids, and standardized steroid-taper protocols should be implemented based on the dose and duration of steroids preoperatively 2
• For patients who have had complete resection of active disease, steroid tapering is particularly important 2
• Monitor for signs of wound healing complications, infection, and adrenal insufficiency in patients who have received corticosteroids before surgery 5
• In case of unexplained, fluid-unresponsive hypotension during or after surgery, consider adrenal insufficiency and administer appropriate steroid doses 5

Exceptions and Nuances

• For patients with adrenal insufficiency, appropriate steroid coverage is necessary during surgery 5, 6
• Some studies suggest that the risk may be lower for certain types of surgeries, such as lumbar decompression surgery, but the safe time interval remains subject to further research 7
• There is conflicting evidence regarding the safety window, with some studies suggesting that injections beyond 4 weeks before surgery may not significantly increase infection risk 4, 8
• However, the most recent and comprehensive meta-analysis supports the 3-month waiting period recommendation 1

Algorithm for Decision-Making

1. If patient has received a corticosteroid injection within 3 months:

   • Delay elective surgery if possible 1
   • If surgery cannot be delayed, implement enhanced infection prevention protocols 2

2. If patient is on chronic steroid therapy:

   • Continue therapy but minimize dose if possible 2
   • Provide appropriate perioperative steroid coverage 5
   • Monitor closely for signs of infection and delayed wound healing 2

3. If patient received injection more than 3 months ago:

   • Proceed with surgery as planned 1
   • No additional precautions needed beyond standard care 8