Perioperative Corticosteroid Coverage

I have a patient who has been treated long term with a low dose of corticosteroids for her arthritis. She wants to have an abdominoplasty early next year. She is healthy otherwise and is a nonsmoker. I will remove slightly less skin than I would have so there is less tension on her incision, but if she will work with me things will go well. I told her she and I would need to discuss her steroid use perioperative, and that her steroid use may delay her healing. More important to me is the possibility of an impaired response to the stress of surgery and anesthesia. This can happen due to the suppression of hypothalamic-pituitary-adrenal axis (adrenal insufficiency) that happens with prolonged corticosteriod use. (photo credit)

I was taught the following (first reference):

In-patient surgery

• Methylprednisone (Solu-Medrol) 20 mg IM on call to surgery


• During surgery infuse hyprocortisone (Solu-Cortef) 100 mg IV over 8 hr


• Day of surgery: hydrocortisone 50-100 mg IV every 8 hr


• POD #1: hydrocortisone 25-50 mg IV every 8 hr


• POD #2: hydrocortisone 25 mg IV every 8-12 hr


• Thereafter: Resume maintenance steroid dose if there are no complications which prolong stressful period, for example, infection.

Out-patient surgery

• Methylprednisolone 20 mg IM on call to surgery


• During surgery infuse hydrocortisone 50 mg IV over 4 hr


• Evening of surgery give double usual daily dose of prednisone


• POD #1: Resume maintenance therapy


• IV fluids should contain saline

I was pleasantly surprised to see that a fellow blogger, Notes from Dr. RW, recently posted on just this subject. He covered the subject from the hospitalist point-of-view. Here is his summary of current recommendations:

Minor procedure (endoscopy, inguinal hernia repair):

• 25 mg hydrocortisone or its equivalent on day of procedure only.

Moderate procedure (abdominal surgery):

• 50-75mg hydrocortisone on day of procedure and taper quickly over 2-3 days to patient’s maintenance dose.

High risk procedure (cardiovascular surgery, extensive abdominal):

• 100-150 mg hydrocortisone initially, then taper over 1-2 days to patient’s maintenance dose.

It is important for all of us (surgeons, anesthesiologist, internist, etc) to remember how long term use of prednisone can affect patients.

References

Hand Clinics--Rheumatoid Arthritis; chief editor Paul Feldon, MD; May 1989;page 119

Perioperative Management of the Rheumatic Disease Patient; Joe T. Kelley III, MD, Doyt L. Conn, MD; Bulletin on the Rheumatic Diseases, Vol 51, No 6 (free access on-line)

Corticosteroid Supplementation for Adrenal Insufficiency; Douglas B. Coursin, MD; Kenneth E. Wood, DO ; JAMA, 2002;287:236-240

What is Adrenal Insufficiency?--EndocrineSurgeon