What to check preoperatively for a patient on long-term steroids (corticosteroids)?

Preoperative Assessment for Patients on Long-Term Steroids

For patients on long-term steroids, continue their usual steroid regimen perioperatively rather than administering routine "stress-dose" steroids, while monitoring for signs of adrenal insufficiency and being prepared to administer rescue doses if needed. 1

Definition of Long-Term Steroid Use

• Chronic steroid therapy is defined as taking ≥20 mg/day prednisone or equivalent for at least 3 weeks 1
• Patients on steroids for >1 year may have hypothalamic-pituitary-adrenal (HPA) axis suppression 1

Preoperative Assessment

• Review steroid dosage, duration, and indication 1
• Assess for signs of Cushing's disease (moon facies, buffalo hump, central obesity, skin thinning) 1
• Check recent disease activity assessment if steroids are for inflammatory conditions 1
• Obtain recent cross-sectional imaging and endoscopy results if patient has inflammatory bowel disease 1

Laboratory Testing

• Testing of HPA axis is not routinely required and does not predict perioperative hypotension or adrenal crisis 1, 2
• Note that HPA testing may reveal adrenal insufficiency but doesn't directly predict clinical manifestations 1

Perioperative Steroid Management

• Patients should continue their usual daily steroid dose during the perioperative period 1
• For patients on oral steroids, convert to equivalent IV dose while nil by mouth (prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg) 1
• Recent evidence does not support routine "push-dose" or "stress-dose" steroids for patients already on chronic steroid therapy 1
• Zaghiyan et al. showed no differences in postural hypotension or adrenal insufficiency between high-dose and low-dose (usual dose) steroid regimens 1

Special Considerations

• Be prepared to administer rescue steroids if unexplained hypotension occurs: 100 mg IV hydrocortisone followed by 50 mg IV hydrocortisone every 6 hours 1
• Monitor closely for signs of adrenal crisis (unexplained hypotension unresponsive to fluid resuscitation) 1
• Patients on chronic steroids have higher surgical complication rates, including increased risk of infections, anastomotic leaks, wound dehiscence, and longer hospital stays 1

Surgical Risk Assessment

• Patients on chronic steroids have a 7-fold increased risk of anastomotic leak in colorectal surgery 1
• Consider diverting stoma for high-risk anastomoses, especially in patients with inflammatory bowel disease on high-dose steroids 1
• Chouairi et al. demonstrated longer hospital stays and higher complication, reintervention, readmission, and mortality rates in patients on chronic steroid therapy 1

Common Pitfalls to Avoid

• Avoid unnecessary administration of high-dose perioperative steroids, as this practice lacks supporting evidence 1, 2
• Don't abruptly discontinue steroids before surgery; maintain at least the usual daily dose 1
• Don't rely solely on HPA axis testing to guide perioperative steroid management 1
• Be vigilant for unexplained hypotension during and after surgery, as this may indicate adrenal crisis requiring immediate steroid administration 1, 3