From the Guidelines
For patients requiring stress dose steroids postoperatively, administer hydrocortisone 100 mg intravenously at the start of surgery, followed by an infusion of 200 mg/24h, and then double the regular oral replacement dose of hydrocortisone for 48 h, or for up to a week following major surgery. This approach is based on the most recent guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency, as recommended by the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK 1. The guidelines emphasize the importance of not interrupting physiological replacement therapy and increasing the daily dose at times of physiological stress.
Key Considerations
- The recommended dose of hydrocortisone for intra-operative steroid replacement is 100 mg intravenously at induction, followed by an immediate initiation of a continuous infusion of hydrocortisone at 200 mg/24h 1.
- For postoperative steroid replacement, the guidelines recommend hydrocortisone 200 mg/24h by i.v. infusion while nil by mouth, or alternatively, hydrocortisone 50 mg every 6 h by i.m. injection 1.
- Patients who should receive stress dosing include those on chronic steroid therapy (equivalent to prednisone ≥5 mg daily for >3 weeks within the past year) or those with known adrenal insufficiency, as they are at risk of adrenal crisis due to suppressed hypothalamic-pituitary-adrenal axes 1.
Clinical Implications
- Inadequate cortisol during surgical stress can lead to hemodynamic instability, hypotension, and even cardiovascular collapse, emphasizing the importance of adequate stress dose steroid coverage 1.
- The guidelines also highlight the need for close monitoring and individualized care, as patients with comorbidities, such as asthma and diabetes, are more vulnerable to adrenal crisis 1.
- It is essential to transition patients back to their maintenance steroid regimen once the acute stress resolves to avoid complications of prolonged high-dose steroid therapy 1.
From the Research
Postoperative Stress Dose Steroids
- The dosage of postoperative stress dose steroids is not explicitly stated in the provided studies, but it is mentioned that glucocorticoids should be supplemented at the same level as that of normal physiological response to surgical stress 2.
- A commonly suggested dosage is approximately 100 mg of cortisol for major surgery, as it induces approximately 5 times the normal secretion 2.
- The use of stress doses of hydrocortisone has been shown to reduce systemic inflammatory response, improve outcome, and reduce chronic stress symptoms in patients undergoing cardiac surgery 3, 4.
- The administration of stress-dose glucocorticoids is required during the perioperative period to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis 2.
- However, some studies suggest that 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 5.
Key Considerations
- The invasiveness of surgery and inhibition of the hypothalamus-pituitary-adrenal axis should be evaluated when determining the need for stress-dose glucocorticoid administration 2.
- Patients with possible adrenal insufficiency require supplemental doses of corticosteroids in the perioperative period 5.
- The dosage and duration of previous corticosteroid therapy, as well as adrenal function testing results, should be considered when determining the need for stress-dose glucocorticoids 5.