Perioperative Stress-Dose Steroids

Abstract

Supraphysiologic corticosteroid doses have routinely been considered the perioperative standard of care over the past six decades for patients on long-term steroid therapy. However, the accumulation of data over this period is beginning to suggest that such a practice may not be necessary. The majority of these studies are retrospective reviews or small prospective cohorts, but there are two small prospective, randomized placebo-controlled trials, one prospective primate trial, and several systematic reviews addressing the issue. Based on this developing evidence, patients on long-term exogenous steroids do not require high-dose perioperative corticosteroids and should instead remain on their baseline maintenance dose, with the understanding that secondary adrenal insufficiency should be considered for unexplained perioperative hypotension in these patients.

Keywords

stress-dose steroids - adrenal insufficiency - corticosteroids - perioperative steroids

• References

• 1 Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002; 287 (2) 236-240
• 2 Salem M, Tainsh Jr RE, Bromberg J, Loriaux DL, Chernow B. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg 1994; 219 (4) 416-425
• 3 Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. J Am Med Assoc 1952; 149 (17) 1542-1543
• 4 Lewis L, Robinson RF, Yee J, Hacker LA, Eisen G. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med 1953; 39 (1) 116-126
• 5 Kehlet H. Clinical course and hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated surgical patients. Copenhagen, Denmark: FADL Forlag ; 1976
• 6 Lal G, Clark OH. Thyroid, Parathyroid, and Adrenal. In: Brunicardi FC, Andersen DK, Billiar TR, , et al, eds. Schwartz's Principles of Surgery. 9^th ed. New York, NY: McGraw Hill; 2010: 1343-1407
• 7 de Lange DW, Kars M. Perioperative glucocorticosteroid supplementation is not supported by evidence. Eur J Intern Med 2008; 19 (6) 461-467
• 8 Brown CJ, Buie WD. Perioperative stress dose steroids: do they make a difference?. J Am Coll Surg 2001; 193 (6) 678-686
• 9 Solem JH, Lund I. Prophylaxis with corticosteroids in surgical patients receiving cortisone or other steroid therapy. Acta Anaesthesiol Scand 1962; 6: 99-105
• 10 Jasani MK, Freeman PA, Boyle JA , et al. Studies in the rise in plasma 11-hydroxycorticosteroids (11-OCHS) in corticosteroid-treated patients with rheumatoid arthritis during surgery: correlations with the functional integrity of the hypothalomo-pituitary-adrenal axis. Q J Med 1968; 37: 407-421
• 11 Kehlet H, Binder C. Adrenocortical function and clinical course during and after surgery in unsupplemented glucocorticoid-treated patients. Br J Anaesth 1973; 45 (10) 1043-1048
• 12 Knudsen L, Christiansen LA, Lorentzen JE. Hypotension during and after operation in glucocorticoid-treated patients. Br J Anaesth 1981; 53 (3) 295-301
• 13 Lloyd EL. A rational regimen for perioperative steroid supplements and a clinical assessment of the requirement. Ann R Coll Surg Engl 1981; 63 (1) 54-57
• 14 Symreng T, Karlberg BE, Kågedal B, Schildt B. Physiological cortisol substitution of long-term steroid-treated patients undergoing major surgery. Br J Anaesth 1981; 53 (9) 949-954
• 15 Shapiro R, Carroll PB, Tzakis AG, Cemaj S, Lopatin WB, Nakazato P. Adrenal reserve in renal transplant recipients with cyclosporine, azathioprine, and prednisone immunosuppression. Transplantation 1990; 49 (5) 1011-1013
• 16 Bromberg JS, Baliga P, Cofer JB, Rajagopalan PR, Friedman RJ. Stress steroids are not required for patients receiving a renal allograft and undergoing operation. J Am Coll Surg 1995; 180 (5) 532-536
• 17 Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations. J Bone Joint Surg Am 1995; 77 (12) 1801-1806
• 18 Mathis AS, Shah NK, Mulgaonkar S. Stress dose steroids in renal transplant patients undergoing lymphocele surgery. Transplant Proc 2004; 36 (10) 3042-3045
• 19 Glowniak JV, Loriaux DL. A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency. Surgery 1997; 121 (2) 123-129
• 20 Thomason JM, Girdler NM, Kendall-Taylor P, Wastell H, Weddel A, Seymour RA. An investigation into the need for supplementary steroids in organ transplant patients undergoing gingival surgery. A double-blind, split-mouth, cross-over study. J Clin Periodontol 1999; 26 (9) 577-582
• 21 Udelsman R, Ramp J, Gallucci WT , et al. Adaptation during surgical stress. A reevaluation of the role of glucocorticoids. J Clin Invest 1986; 77 (4) 1377-1381
• 22 Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg 2008; 143 (12) 1222-1226
• 23 Zaghiyan K, Melmed G, Murrell Z, Fleshner P. Are high-dose perioperative steroids necessary in patients undergoing colorectal surgery treated with steroid therapy within the past 12 months?. Am Surg 2011; 77 (10) 1295-1299
• 24 Zaghiyan K, Melmed G, Murrell Z, Fleshner P. Safety and feasibility of using low-dose perioperative intravenous steroids in inflammatory bowel disease patients undergoing major colorectal surgery: a pilot study. Surgery 2012; 152 (2) 158-163
• 25 Yong SL, Marik P, Esposito M , et al. Supplemental perioperative steroids for surgical patients with adrenal insufficiency. Cochrane Database Syst Rev 2009; 4