PERIOPERATIVE STEROIDS IN SURGICAL PATIENTS - Satheesh Yalamarthi
INTRODUCTION
Some patients on admission to surgical wards for elective or emergency operations or with an acute illness are taking corticosteroids for various medical reasons. There is general agreement among clinicians that additional steroids are required, but there is no consensus on dosage or duration.
EFFECTS OF SURGERY / ACUTE ILLNESS
There is increased secretion of ACTH and Cortisol as a normal response to illness or surgery.In a normal individual there is a daily secretion of 30mg of cortisol. In response to minor surgery there is a minimal increase in cortisol secretion (50mg) and a 2/3-fold increase (75-100mg) after major surgery. (Salem et al - Ann Surg 1994)
WHY DO PATIENTS REQUIRE ADDITIONAL STEROIDS
Patients who are on regular steroids tend to have a suppressed hypothalamo-pitutary-adrenal axis, which can cause an impaired stress response. Without adequate cortisol release, these patients are at risk of developing hypoadrenal crisis (e.g. circulatory collapse and shock).
HYPOTHALAMO-PITUTARY-ADRENAL (HPA) SUPPRESSION
However, not all patients receiving regular steroids will have this suppression depending on the dose and duration of current steroid treatment.
Adrenal suppression does not occur in patients with a daily dosage of less than 5mg prednisolone (or equivalent). (La Rochelle et al - Am J Med 1993). In practice, it is often assumed that replacement will only be needed in patients taking more than 10 mg prednisolone. (Nicholson et al - Anaesthesia 1998)
Adrenal suppression can occur as early as one week after commencing steroid treatment. (Salem et al - Ann Surg 1994).
The recovery of normal adrenal function after stopping steroids may take a variable length of time (Nicholson et al - Anaesthesia 1998) and patients who have received Corticosteroids within the last 3 months should be presumed to have some degree of HPA suppression. (Plumpton et al - Anaesthesia 1969, Nicholson et al - Anaesthesia 1998)
It should be remembered that HPA suppression can occur in patient of high doses of inhaled steroids. (Lipworth 1999)
PREOPERATIVE TESTS
The following tests can be used in clinical studies but are not routinely used in clinical practice:
Serum and urinary cortisol
Short synacthen test
Insulin tolerance
test
CRH
WHO NEEDS ADDITIONAL STEROIDS
Many consultants prefer to give steroid replacement routinely rather than risk peri-operative hypoadrenal crisis. (Krasner -JAMA 1999)
Based on a review of literature, the recommendation is that the following groups of patients require additional steroid cover during surgery or acute illness.
CONVERSIONS
Prednisolone 5 mgs is equivalent to
|
Betamethasone 750 microgms |
|
Cortisone acetate 25 mgs |
|
Dexamethasone 6 mgs |
|
Hydrocortisone 20 mgs |
|
Methylprednisolone 4 mgs |
HOW MUCH OF STEROIDS IS NEEDED
The dose of replacement steroid is controversial and early regimens used very high doses. (Fraser et al -JAMA 1952). Several subsequent small studies have suggested that high doses are unnecessary and may cause impaired wound healing, delayed recovery and increased post-operative morbidity. (Symerng et al - BJA 1981, Bromberg et al -Transplantation 1991, Friedman et al -JBJS 1995, Goforth -J Foot Surg 1980, Nicholson - Anaesth 1998):
The current recommendation is to use smaller doses.
METHOD OF DELIVERY AND DOSAGE
No RCTs have compared Infusion or Bolus delivery. However,infusion is preferable as it avoids large increases caused by Bolus injection. (Nicholson et al -Anaesth 1998). However infusion may present more practical difficulties.
|
Dose |
Type of surgery |
Recommended dose |
|
|
Patients currently taking steroids |
|||
|
<10 mg/day |
Minor / Moderate / Major |
Additional steroid cover is not required (it can be assumed that patients will have a normal HPA response) |
|
|
10+ mg/day |
Minor surgery |
25 mg of hydrocortisone at induction and resume normal medications post-op |
|
|
10+ mg/day |
Moderate surgery |
Usual dose of steroid pre-operatively and 25 mg of hydrocortisone IV at induction followed by 25 mg IV 8-hourly for 24 hrs, then recommence pre-operative dosage |
|
|
10+ mg/day |
Major surgery |
Usual dose of steroid pre-operatively and 50 mg of hydrocortisone at induction followed by 50 mg IV 8-hourly for 48 –72 hrs. Maintain this infusion until light diet started and normal pre-operative dose is recommenced. |
|
|
Patients who have stopped taking steroids |
|||
|
10+ mg/day within 3 months of surgery |
Treat as above. |
||
|
> 3 months |
No peri-operative steroid cover is necessary |
||
REFERENCES
7 May 2002