From an endocrinology standpoint, can the planned surgery proceed if the patient’s diabetes, thyroid function, adrenal status, calcium/vitamin D levels, and any other endocrine disorders are fully optimized?

Preoperative Endocrine Clearance for Surgery

Yes, surgery can proceed from an endocrinology standpoint once all endocrine disorders are fully optimized, with specific attention to adrenal insufficiency requiring perioperative stress-dose glucocorticoid coverage, hypothyroidism requiring correction before moderate-to-severe cases, and diabetes requiring a structured perioperative glucose management plan. 1, 2

Critical Endocrine Optimization Requirements

Adrenal Insufficiency - Highest Priority

• All patients with known or suspected adrenal insufficiency must receive stress-dose hydrocortisone perioperatively to prevent life-threatening adrenal crisis. 1, 3
• For major surgery: Administer hydrocortisone 100 mg IV at induction, followed by continuous infusion of 200 mg/24 hours until oral intake resumes. 1
• For intermediate surgery: Give hydrocortisone 100 mg IV at induction, then double the regular glucocorticoid dose for 48 hours postoperatively. 1
• For minor procedures without general anesthesia: Double the morning hydrocortisone dose preoperatively. 1
• Anyone receiving prednisolone ≥5 mg daily (or hydrocortisone equivalent ≥20 mg daily) for ≥1 month is at risk for hypothalamic-pituitary-adrenal axis suppression and requires stress dosing. 3, 2

Thyroid Disease Management

• Patients with mild hypothyroidism can safely proceed with elective surgery. 2
• Elective surgery must be postponed for patients with moderate or severe hypothyroidism until they are euthyroid. 2
• Patients with mild hyperthyroidism can undergo elective surgery with preoperative beta blockade. 2
• Elective surgery should not proceed for patients with moderate or severe hyperthyroidism until they achieve euthyroid status. 2
• Replacement for significant hypothyroidism is recommended preoperatively. 4

Diabetes Mellitus Optimization

• Perioperative management must include bedside glucose monitoring regardless of diabetes type. 2
• The management plan should be based on diabetes type, current medications, glycemic control status, and surgical procedure type. 2
• There is increasing evidence that maintenance of normal blood glucose perioperatively benefits both diabetic and non-diabetic patients. 5

Calcium and Parathyroid Assessment

• Check serum calcium and parathyroid hormone levels preoperatively. 4
• If primary hyperparathyroidism is suspected, seek advice from a specialist with expertise in this condition before proceeding. 4
• Hypocalcemia may be asymptomatic or associated with fatigue, irritability, abnormal involuntary movements, or QT prolongation on electrocardiogram. 4
• Targeted calcium monitoring should be considered perioperatively as this is a vulnerable time for hypocalcemia. 4

Pituitary Function Evaluation (When Applicable)

• Routine endocrine evaluation of all anterior pituitary axes to assess for hypopituitarism is recommended when pituitary pathology is suspected. 4
• Replacement for adrenal insufficiency and significant hypothyroidism is recommended in all patients preoperatively. 4
• Routine prolactin and IGF-1 testing is recommended in patients with suspected nonfunctioning pituitary adenomas to rule out hypersecretion. 4

Preoperative Laboratory Assessment

Essential Screening Tests

• Full blood count including hemoglobin, ferritin, folate, and vitamin B12 levels. 4
• Serum 25-hydroxyvitamin D levels. 4
• Serum calcium levels. 4
• Serum/plasma parathyroid hormone levels. 4
• HbA1c, lipid profile, liver and kidney function tests. 4

Additional Considerations for Specific Procedures

• For malabsorptive procedures (e.g., bariatric surgery): Consider checking serum vitamin A, zinc, copper, and selenium levels. 4
• Nutritional deficiencies should be corrected preoperatively as patients have an increased risk of deficiencies postoperatively. 4

Critical Pitfalls to Avoid

• Never delay stress-dose glucocorticoid administration in patients with known or suspected adrenal insufficiency—this is a potentially fatal error. 1, 3
• Do not use dexamethasone as first-line therapy in suspected primary adrenal insufficiency as it lacks mineralocorticoid activity. 1, 3
• Do not proceed with elective surgery in patients with moderate-to-severe hypothyroidism or uncontrolled hyperthyroidism. 2
• Patients with pheochromocytoma must be identified and properly treated with alpha-adrenergic blockade before surgery to prevent perioperative cardiovascular complications. 2, 5
• If in doubt about the need for glucocorticoids, they should be given as there are no long-term adverse consequences of short-term administration. 1

Postoperative Endocrine Management

• After stress dosing, taper back to maintenance glucocorticoid dose within 48 hours for uncomplicated cases, or up to a week for major/complicated surgery. 1
• Continue monitoring for signs of adrenal crisis, thyroid storm, or severe hypoglycemia in the immediate postoperative period. 3, 6
• Children with adrenal insufficiency are more vulnerable to glycemic control problems than adults and require frequent blood glucose monitoring. 1