What is the rationale for administering steroids intravenously (IV) during surgery?

Rationale for Intravenous Steroids During Surgery

The primary rationale for administering IV steroids intraoperatively is to prevent adrenal crisis in patients on chronic steroid therapy who cannot produce adequate endogenous cortisol in response to surgical stress, and to provide equivalent dosing when patients are unable to take oral medications. 1, 2

Primary Indications for Intraoperative IV Steroids

1. Continuation of Chronic Steroid Therapy

• Patients on chronic steroid therapy (≥20 mg/day prednisone or equivalent for ≥3 weeks) must continue their usual steroid dose during surgery via IV route when oral intake is not possible. 1, 2
• The conversion is straightforward: prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg. 1, 2
• This is not about "stress dosing" but simply maintaining baseline steroid replacement to prevent adrenal insufficiency. 1

2. Prevention of Adrenal Crisis

• Patients with hypothalamic-pituitary-adrenal (HPA) axis suppression from chronic steroid use cannot mount an adequate cortisol response to surgical stress. 1, 2
• If unexplained, fluid-unresponsive hypotension occurs intraoperatively, administer 100 mg IV hydrocortisone immediately as a rescue dose, followed by 50 mg IV hydrocortisone every 6 hours. 1, 2, 3
• This represents treatment of suspected adrenal crisis, which can be fatal if not recognized and treated promptly. 3

Important Nuances and Controversies

The "Stress Dose" Debate

• Current evidence does NOT support routine "push-dose" or "stress-dose" steroids (200-300 mg hydrocortisone) for all patients on chronic steroids. 1
• The World Journal of Emergency Surgery guidelines explicitly state there is no evidence supporting routine stress dosing, and patients can maintain adequate endogenous steroid production if they continue their usual dose. 1
• However, many anesthesiologists still use stress dosing in practice due to the minimal risk compared to the catastrophic consequences of adrenal crisis. 1

When Stress Dosing May Still Be Used

• In patients with documented or presumed severe HPA suppression (high-dose chronic therapy), some centers still administer perioperative stress-dose steroids despite limited evidence, as the risk appears minimal compared to adrenal crisis. 1
• The practical approach: continue usual dose for most patients, but have a low threshold to administer rescue steroids if unexplained hypotension develops. 1, 2

Alternative Rationale: Anti-Inflammatory Effects (Context-Specific)

In Cardiac Surgery with Cardiopulmonary Bypass

• Steroids are used to modulate the vigorous systemic inflammatory response triggered by cardiopulmonary bypass. 4, 5
• Preoperative methylprednisolone (30 mg/kg) combined with intraoperative dosing reduces inflammatory mediator expression (IL-6, MCP-1, ICAM-1) and improves oxygen delivery in pediatric cardiac surgery. 4
• This represents a distinct indication from HPA axis protection—it's about dampening surgical inflammation. 4, 5

In Hepatic Resection

• Preoperative high-dose methylprednisolone (30 mg/kg or 500 mg) reduces postoperative IL-6, IL-8, and C-reactive protein levels, and may shorten hospital stay. 6, 7
• The mechanism involves elevating anti-inflammatory IL-10 while suppressing pro-inflammatory cytokines. 7
• However, this practice is not universally adopted and remains investigational. 6, 7

Critical Pitfalls to Avoid

1. Assuming All Patients Need Stress Dosing

• Do not routinely administer high-dose stress steroids to all patients on chronic steroids—continue their usual equivalent IV dose instead. 1
• Reserve rescue dosing (100 mg hydrocortisone IV) for unexplained hypotension unresponsive to fluids and vasopressors. 1, 3

2. Ignoring Increased Surgical Risk

• Patients on chronic steroids have a 7-fold increased risk of anastomotic leak in colorectal surgery and higher rates of wound dehiscence, infections, and mortality. 1, 2, 8
• In inflammatory bowel disease patients undergoing high-risk anastomoses, consider diverting stoma if on high-dose steroids preoperatively. 2
• The British Society of Gastroenterology recommends stopping or minimizing steroids before elective surgery when possible to reduce complications. 1

3. Failing to Recognize Adrenal Crisis

• Adrenal crisis presents as unexplained hypotension that does not respond to fluid resuscitation or vasopressors during or immediately after surgery. 1, 3
• Treatment should not be delayed—administer 100 mg hydrocortisone IV immediately if adrenal crisis is suspected. 3
• Delayed recognition and treatment can be fatal. 3

Practical Algorithm for Intraoperative Steroid Administration

Step 1: Identify patients on chronic steroids

• Chronic steroid therapy = ≥20 mg/day prednisone equivalent for ≥3 weeks. 1, 2

Step 2: Continue usual dose via IV route

• Convert oral dose to IV equivalent (prednisolone 5 mg = hydrocortisone 20 mg). 1, 2
• Administer as scheduled doses or continuous infusion. 1

Step 3: Monitor for adrenal crisis

• Watch for unexplained hypotension unresponsive to fluids/vasopressors. 1
• If suspected, give 100 mg hydrocortisone IV immediately, then 50 mg IV q6h. 1, 3

Step 4: Special considerations

• In cardiac surgery with CPB or major hepatic resection, preoperative high-dose methylprednisolone may be considered for anti-inflammatory effects, though this remains investigational. 4, 6, 7
• Anesthesiologists may give a single dose of dexamethasone 4 mg at induction for antiemetic/anti-inflammatory effects, which is distinct from HPA axis protection. 1