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