Can a 38-year-old euthyroid female with thyroid eye disease on chronic glucocorticoids and mycophenolate be cleared for bilateral orbital decompression, and should she receive stress-dose hydrocortisone before anesthesia induction?

Preoperative Clearance for Bilateral Orbital Decompression in Thyroid Eye Disease

Yes, this patient can be cleared for bilateral orbital decompression, and she should receive stress-dose hydrocortisone 100 mg IV at anesthesia induction given her chronic glucocorticoid and immunosuppressant therapy. 1

Surgical Clearance Assessment

Thyroid Status - Cleared

• The patient is euthyroid with TSH 0.82 (normal range 0.4-3.0), FT4 1.02, and FT3 4.39, which is optimal for proceeding with orbital decompression. 1, 2
• Maintaining euthyroid status is crucial because both hyper- and hypothyroidism worsen thyroid eye disease and surgical outcomes. 3, 2
• The patient appropriately discontinued methimazole and propranolol after achieving stable euthyroid status. 2

Cardiovascular Status - Cleared

• Vital signs are stable (BP 120/90, HR 87, no palpitations or tremors currently). 1
• No active hyperthyroid symptoms that would increase perioperative cardiac risk. 1
• Prior palpitations and easy fatigability have resolved, indicating good thyroid control. 2

Hematologic Parameters - Cleared

• Hemoglobin 139 g/L and hematocrit 0.42 are adequate for surgery. 4
• Platelet count 321 and normal coagulation studies (PT 12.6, PTT 29.8, INR 0.93) indicate no bleeding risk. 4
• White blood cell count 9.1 with neutrophil fraction 0.46 is acceptable despite mycophenolate therapy. 5

Metabolic and Renal Function - Cleared

• Normal electrolytes (Na 141, K 3.58, Cl 102) and renal function (creatinine 58.28 μmol/L, BUN 3.5). 1
• Normal glucose metabolism (FBS 5.32, HbA1c 5.6%) reduces perioperative complications. 1

Imaging Requirement

• The planned cranial CT with orbits and paranasal sinuses is appropriate and necessary before proceeding, as CT provides essential information about orbital muscle volumes, fat volumes, and osseous anatomy critical for surgical planning. 1
• CT imaging is specifically recommended when orbital decompression is a surgical consideration in thyroid eye disease. 1

Stress-Dose Glucocorticoid Management

Indication for Stress Dosing

This patient requires perioperative stress-dose hydrocortisone because:

• She has received chronic glucocorticoid therapy (steroids for eye pain, followed by 10 sessions of radiation therapy, now on mycophenolate). 1
• Orbital decompression under general anesthesia constitutes major surgery requiring stress-dose supplementation. 1
• The surgical stress response is most prominent with procedures involving open surgery and general anesthesia. 1

Specific Dosing Protocol

Administer hydrocortisone 100 mg IV at anesthesia induction, then 50-100 mg IV every 6-8 hours for the first 24-48 hours postoperatively. 1, 6

Rationale for this regimen:

• Hydrocortisone provides both glucocorticoid and mineralocorticoid activity, which is physiologically appropriate during acute surgical stress. 7, 6
• The dose of 100 mg IV at induction followed by 50-100 mg every 6-8 hours represents approximately 10-20 times the baseline maintenance dose, consistent with stress dosing principles. 7, 6
• This prevents progressive loss of vasomotor tone and impaired alpha-adrenergic receptor responses that occur with insufficient cortisol during surgical stress. 1

Postoperative Tapering

• Continue stress-dose hydrocortisone (50-100 mg IV every 6-8 hours) until the patient is clinically stable and tolerating oral intake, typically 24-48 hours. 1
• Once stable and taking oral medications, transition to double the pre-stress oral glucocorticoid dose for 48 hours if recovery is uncomplicated. 7
• Then taper stress-dose corticosteroids over 5-7 days back to baseline maintenance therapy. 7
• Do not reduce or withdraw steroid supplementation if the patient develops postoperative fever, as persistent pyrexia may indicate adrenal insufficiency. 1

Critical Perioperative Monitoring

Signs of Impending Adrenal Crisis

Maintain high vigilance for early signs of adrenal insufficiency, which include: 1

• Non-specific malaise, somnolence, or cognitive dysfunction (test response to 100 mg hydrocortisone). 1
• Orthostatic hypotension (monitor sitting and supine blood pressure). 1
• Hyponatremia (though not always present). 1
• Volume-resistant hypotension is a late and potentially agonal sign. 1

Immunosuppression Considerations

• The patient is on mycophenolate, which combined with perioperative steroids increases infection risk. 8, 5
• Maintain heightened awareness for sepsis, particularly the combination of steroid therapy and any neutropenia. 8
• Implement meticulous wound care with heightened infection surveillance postoperatively. 8

Common Pitfalls to Avoid

Do not simply convert maintenance glucocorticoids to an equivalent dose without adding stress supplementation—this provides inadequate coverage during major surgery. 7

Do not use etomidate for anesthesia induction, as it rapidly suppresses cortisol production by inhibiting 11-beta-hydroxylase. 1

Do not delay or withhold stress-dose hydrocortisone based on concerns about hyperglycemia or fluid retention—the short-term use during uncomplicated surgery carries minimal risk compared to the potentially fatal consequences of adrenal crisis. 1

Ensure the patient and surgical team understand sick-day rules: if postoperative complications develop (fever, vomiting, infection), continue or increase glucocorticoid supplementation rather than tapering. 1, 8