Corticosteroids and Glycocalyx Shedding During Surgery
Direct Answer
The available evidence shows that high-dose methylprednisolone (30 mg/kg) reduces glycocalyx shedding in neonates undergoing complex cardiac surgery, but this protective effect does not extend to older infants or less complex procedures. 1
Evidence for Glycocalyx Protection
In neonates undergoing complex open-heart surgery, intraoperative administration of 30 mg/kg methylprednisolone significantly reduced relative increases of syndecan-1 (a biomarker of glycocalyx degradation) at weaning from cardiopulmonary bypass (P = 0.008) and at 6 hours postoperatively (P = 0.018). 1
However, this protective effect was not observed in older infants and young children undergoing ventricular or atrioventricular septal defect repair with shorter ischemia times, regardless of whether methylprednisolone was given after anesthesia induction or in the cardiopulmonary bypass prime solution. 1
The mechanism appears related to attenuation of the systemic inflammatory response, as corticosteroids are known to modify the pro-inflammatory cytokine profile during cardiac surgery. 2
Clinical Context and Limitations
Glycocalyx shedding occurs in both on-pump and off-pump coronary artery bypass surgery, with release of atrial natriuretic peptide (ANP) preceding and potentially initiating this shedding process—this occurs independently of the inflammatory cytokine response. 3
The protective effect of corticosteroids on glycocalyx appears limited to specific high-risk populations (neonates with complex cardiac surgery) and may not translate to routine surgical procedures or adult patients. 1
Critical Surgical Risks to Consider
Despite any potential glycocalyx-protective effects, corticosteroid use in the perioperative period carries substantial risks that must be weighed carefully:
Patients undergoing surgery while on corticosteroids have increased risk of postoperative infectious complications, venous thromboembolism, and anastomotic leak, with risks greatest for those taking high-dose steroids (≥40 mg prednisolone equivalent). 4
Preoperative steroid use increases superficial surgical site infections from 2.9% to 5% (OR 1.724), deep infections from 0.8% to 1.8% (OR 2.353), and mortality nearly fourfold from 1.6% to 6.0% (OR 3.920). 5
For elective surgery in patients with inflammatory bowel disease, corticosteroids should be stopped or minimized preoperatively wherever possible to reduce these complication risks. 4
Practical Algorithm for Inflammatory/Autoimmune Disease Patients
For patients with inflammatory or autoimmune diseases on chronic corticosteroids undergoing surgery:
Continue the patient's usual daily corticosteroid dose (converted to IV equivalent when NPO) rather than administering supraphysiologic stress doses—prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg. 4, 6
Do not routinely administer high-dose steroids (200-300 mg hydrocortisone) for glycocalyx protection or stress coverage, as current evidence does not support this practice and it increases complication risks. 6, 7
Reserve rescue dosing (100 mg hydrocortisone IV) only for unexplained hypotension unresponsive to fluids and vasopressors, followed by 50 mg IV every 6 hours. 6
For patients on ≥20 mg prednisolone equivalent who have been on therapy for ≥4 weeks, provide equivalent IV hydrocortisone while NPO in the perioperative period. 4
Key Pitfall to Avoid
The single most important pitfall is administering high-dose "stress steroids" routinely to all patients on chronic corticosteroids based on outdated protocols. This practice lacks evidence for benefit, increases surgical complications including wound dehiscence and infections, and does not provide meaningful glycocalyx protection except in the narrow context of neonatal complex cardiac surgery. 6, 1, 5