Monday, March 16, 2009

Requirement of Perioperative Stress Doses of Corticosteroids -- an Article Review

If you refer back to my November 3, 2007 post you will see that I was taught that patients on long term corticosteroids need to have “extra” doses or “stress” doses of corticosteroids perioperatively. It was nice to see this recent article in the Archive of Surgery Journal (full reference below). The logic of the perioperative stress doses is to cover the impaired response to the stress of surgery and anesthesia due to the suppression of hypothalamic-pituitary-adrenal axis (adrenal insufficiency) that happens with prolonged corticosteriod use.

Their stated objective was

To determine the requirement for perioperative supplemental (stress) doses of corticosteroids in patients receiving long-term corticosteroid therapy and undergoing a surgical procedure.

They chose to do a review of the literature, looking for all relevant clinical trials that studied the role of perioperative corticosteroids and adrenal crisis in patients taking long-term therapeutic doses of corticosteroids. They searched the National Library of Medicine's MEDLINE database for relevant studies in any language published from January 1, 1966, through July 31, 2007. Keywords for the search were perioperative care or perioperative or surgery and adrenal cortex hormones or corticosteroids. The search was limited to studies involving humans and adults.

They found nine studies that meet their requirements. They studies involve a total of 315 patients who underwent 389 surgical procedures.

Two of the studies were prospective, double-blind, randomized, placebo-controlled studies in which patients received perioperative stress doses of corticosteroids or placebo together with their usual maintenance dose of corticosteroid.

In 2 studies, corticosteroid therapy was stopped before surgery (18 and 36 hours before surgery). Stress doses of corticosteroids were not administered.

In an additional 5 studies patients were followed up after receiving only their usual daily maintenance dose of corticosteroid. Stress doses of corticosteroids were not administered.

Their results

The 2 randomized placebo-controlled studies included in this review did not detect a difference in the hemodynamic profile of patients treated with stress doses of corticosteroids compared with patients treated with their usual dose of corticosteroid alone.

These results are supported by the 5 cohort studies in which patients received their usual daily dose of corticosteroid without the addition of stress doses of corticosteroids; none of the patients in those 5 studies developed an adrenal crisis.

One patient in each of the studies by Jasani et al and Kehlet and Binder developed a possible adrenal crisis that responded rapidly to hydrocortisone treatment; in those patients, corticosteroid therapy was stopped 36 and 48 hours before surgery.

Their conclusion is that the data suggest patients receiving long-term corticosteroid therapy do not require stress doses of corticosteroids. They stress that these patients should continue to receive their usual daily dose of corticosteroid.

They also stress

These recommendations do not apply to patients who receive physiologic replacement doses of corticosteroids because of primary dysfunction of the HPA axis (eg, patients with primary adrenal failure due to Addison disease, with congenital adrenal hyperplasia, or with secondary adrenal insufficiency due to hypopituitarism). It is likely that these patients are unable to increase endogenous cortisol production in the face of stress. These patients require adjustment of their glucocorticoid dose during surgical stress under all circumstances.

REFERENCE

Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Literature; Arch Surg, Dec 2008; 143: 1222 – 1226; Paul E. Marik; Joseph Varon


Perioperative Steroid Coverage (my blog post; November 3, 2007)

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