FRCA Notes

Perioperative Management of Patients Taking Glucocorticoids

This topic comes from the Core curriculum: 'Discusses how to manage drug therapy for co-existing disease in the perioperative period including...steroids'.

It was the subject of a CRQ in 2023 (30% pass rate), with marks lost on 'definition and causes of adrenal insufficiency and peri-operative management of patients on steroids'.

Resources

  • Patients with adrenal insufficiency, or taking physiological replacement doses of corticosteroids, are at significant risk of perioperative adrenal crisis
  • Indeed, the risk-ratio for all-cause mortality is between 2.2 (men) and 2.9 (women) for those with adrenal insufficiency
  • They must be given 'stress' doses of steroid in this period, as their HPA axis is unable to generate sufficient endogenous steroid to meet the demands of a stressful situation
  • If in doubt about the need for glucocorticoids, they should be given anyway as there are no long-term adverse consequences of short-term glucocorticoid administration
  • 0.7% of the population are prescribed long-term oral corticosteroid therapy
  • The incidence of intrinsic adrenal insufficiency is significantly less (approximately 0.007%)

  • In the paediatric population, adrenal insufficiency overall is rare 0.35/100,000
    • Primary adrenal insufficiency, of which CAH is the commonest aetiology, occurs in 1-8/10,000 live births
    • Secondary adrenal insufficiency occurs in approximately 1 in 10,000 children

Exogenous steroids

  • HPA axis suppression will occur if steroid is administered for four weeks or longer at an equivalent daily dose of:
    • Adults: 5mg prednisolone
    • Paediatrics: 10-15mg/m2 hydrocortisone
  • Of note, the route of administration is unimportant; oral, inhaled, intranasal, intra-articular or topical all count
  • This is the most common cause of adrenal insufficiency that anaesthetists will encounter
Steroid Dose equivalent Relative glucocorticoid potency Relative mineralocorticoid potency
Hydrocortisone 20mg 1 1
Prednisolone 5mg 4 0.6
Methylprednisolone 4mg 5 0.25
Triamcinolone 4mg 5 0
Dexamethasone 0.75mg 25 0
Betamethasone 0.75mg 25 0

Pathologies

  • Typically secondary hypoadrenalism causes an Addisonian state, i.e. some issue 'upstream' on the HPA axis:
    • Pituitary disease e.g. post-resection, Sheehan's syndrome, SAH, trauma
    • Hypothalamic disease

  • Primary hypoadrenalism is less common
    • Autoimmune disease
    • TB
    • Post-surgical resection
    • Haemorrhagic e.g. Waterhouse-Friderichsen syndrome
    • CAH
    • Suppression by drugs e.g. etomidate, ketoconazole

  • Patients on long-term steroid therapy may experience a number of physiological changes with perioperative implications:
Physiological effect Perioperative consequence
Hypertension Cardiovascular instability can occur and should be managed accordingly
Hypokalaemia Risk of cardiac arrhythmias, ensure >3.0mmol/L
Adrenal suppression Perioperative steroid replacement
Diabetes mellitus/hyperglycaemia Impaired wound healing
Immunosuppression Risk of post-operative infections
Obesity Multiple sequelae
Thin skin & easy bruising Risk of pressure injury; meticulous positioning/padding required


Perioperative management of the patient with adrenal insufficiency/receiving exogenous steroids


  • Patients with long-standing adrenal insufficiency are often well informed about their disease
  • Relevant history includes:
    • History of steroid self-management
    • History of adrenal crisis
    • Personalised adjustments for illness/injury/post-operative recovery
  • The dose, route and frequency of steroid therapy, including whether their course is tapering or not, is necessary

  • Close liaison with the patient's Endocrinology team to enable an individualised perioperative plan for steroid management

Adrenal insufficiency (any cause)

  • 100mg hydrocortisone IV at induction of anaesthesia
    • Includes regional anaesthesia
    • Includes other procedures such as endoscopy, joint reductions and TVEC
    • Dexamethasone alone is inadequate in patients with primary adrenal insufficiency as it has no mineralocorticoid activity

  • Continuous infusion of 200mg hydrocortisone/24hrs immediately thereafter
    • Continue until the patient can take double their usual oral glucocorticoid dose by mouth
    • Alternative is 50mg QDS IM hydrocortisone
    • This should then be tapered back to the appropriate maintenance dose
    • Can typically start tapering after 48hrs, but may be 24hrs e.g. ERAS or up to a week e.g. complex surgery

Exogenous steroid therapy without primary adrenal insufficiency

  • If patient is taking adrenocortical suppressant doses of steroids (see above) without primary adrenal insufficiency, then dexamethasone 6-8mg may be used instead
  • This will cover the first 24hr period

  • After 24hrs patient should either:
    • Commence 200mg hydrocortisone/24hr infusion (or 50mg IM QDS) if unable to take oral steroids e.g. NBM, PONV etc.
    • Re-commence their oral steroid, at double dose for at least 48hrs then taper

Obstetrics

  • Women may require a higher maintenance dose from the 20th week onwards
  • Stress dose supplementation (100mg at onset of labour then 200mg/24h infusion) should occur
  • If undergoing LSCS, rules as above apply

  • Continuous infusion of 200mg/24hrs until the patient can take double their usual oral glucocorticoid dose by mouth
  • This should then be tapered back to the appropriate maintenance dose (typically 48hrs, but may be 24hrs e.g. ERAS or up to a week e.g. complex surgery)
  • Ongoing Endocrinology input where necessary
  • Critical illness or other major complications excite a prolonged stress response; steroid supplementation should reflect this
  • Frequent blood glucose monitoring, especially in paediatric population

  • The incidence of adrenal crisis is approximately 8 per 100 patient years
  • The prevalence of adrenal crisis for inpatients with adrenal insufficiency, including elective surgical patients, is up to 9%

  • Features include:
    • Non-specific malaise, cognitive dysfunction, somnolence or obtunded conscious level
    • Lying/standing NIBP may detect orthostatic hypotension
    • Typically hyponatraemic
    • Raised CRP (although of limited benefit in post-operative patients)
    • Persistent pyrexia
      • Often attributed to sepsis and treated with antibiotics
      • Should not withdraw steroid supplementation in pyrexial patients
    • Volume-resistant hypotension is a late (/agonal) event