Perioperative management of patients on corticosteroids
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In these annotated PowerPoints I discuss the evaluation and perioperative management of patient taking or who have taken steroids. I discuss how to determine if the adrenal axis is suppressed and how to provide supplemental glucocorticoids if needed. Remember to download these slides to see the annotations for each slide.
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Perioperative management of patients on corticosteroids
- 1. Perioperative Management of Patients Taking Glucocorticoids Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine The information contained in these slides is for educational purposes only and not meant to guide clinical care. Please refer to package inserts and guidelines for prescribing information.
- 2. • A 67 yo M with COPD is undergoing a laparoscopic cholecystectomy in 1 day. He has taken week long prednisone tapers for AECOPD 4 times this year. Last taper was 1 month ago. What do you recommend? A. No testing of HPA axis function. No steroid supplementation. B. Test HPA axis function and base steroid supplementation on results. C. No testing of HPA axis function. Give 50 mg hydrocortisone IV before procedure followed by 25 mg Q8 hrs for 24 hrs. D. No testing of HPA axis function. Give 100 mg hydrocortisone IV before procedure followed by 50 mg Q8 hrs for 24 hrs. Taper dose by 50% each day. Pretest
- 3. • Suppression of hypothalamic-pituitary-adrenal axis • Impaired wound healing • Increased skin fragility • Increased risk of infection • Increased risk of GI bleeding and ulcer • Hyperglycemia • Hypertension • Fluid retention Glucocorticoids have a variety of effects in the perioperative period
- 4. • Normal basal cortisol secretion: 8-10mg/day • Minor procedure • Up 50 mg/day • Returns to baseline with 24 hrs • Moderate procedure • Up to 75-100 mg/day • Returns to baseline by day 5 • Major procedure • Up to 200 mg/day • Returns to baseline by day 5 Cortisol secretion is increased by surgery and is proportional to degree of surgical stress
- 5. • Morning prednisone < 5mg/day for any duration (Am J Med 1993;95:258) • Any dose of glucocorticoids for < 3 weeks (NEJM 2003;348:727) • Prednisone < 10mg every other day (NEJM 1968;278:405) Nonsuppressed HPA Axis
- 6. • Prednisone > 20mg daily for > 3 weeks • On glucocorticoids with clinical Cushing’s syndrome Suppressed HPA Axis
- 7. • Everyone else with steroid exposure • Don’t forget • high dose inhaled steroids • > 2gm/day chronic high potency topical steroids • 3 or more intraarticular or spinal injections w/in 3 months of surgery Unknown HPA Axis Suppression
- 8. 1. Morning serum cortisol • OK > 10 mcg/dl • Impaired HPA axis < 5 mcg/dl • Unknown 5-10 mcg/dl 2. ACTH Stimulation Test • Use in those with intermediate results of serum cortisol or is not morning • Adequate HPA axis cortisol > 18 mcg/dl 30 minutes after 250 mcg ACTH Patients with unknown HPA axis function should undergo preoperative testing
- 9. Steroid Dose Minor procedure Usual morning dose only Moderate procedure (general, joint replacement, lower extremity revascularization) Usual morning dose PLUS 50 mg hydrocortisone IV before procedure and 25 mg Q8 hrs for 24 hrs. Then resume usual dose. Major procedure (larger, prolonged surgery, CABG) Usual morning dose PLUS 100 mg hydrocortisone IV before procedure and 50 mg Q8 hrs for 24 hrs. Taper dose by 50% each day thereafter until reach usual dose. Supplemental perioperative glucocorticoid dosing
- 10. • A 67 yo M with COPD is undergoing a laparoscopic cholecystectomy in 1 day. He has taken week long prednisone tapers for AECOPD 4 times this year. Last taper was 1 month ago. What do you recommend? A. No testing of HPA axis function. No steroid supplementation. B. Test HPA axis function and base steroid supplementation on results. C. No testing of HPA axis function. Give 50 mg hydrocortisone IV before procedure followed by 25 mg Q8 hrs for 24 hrs. D. No testing of HPA axis function. Give 100 mg hydrocortisone IV before procedure followed by 50 mg Q8 hrs for 24 hrs. Taper dose by 50% each day. Posttest
Editor's Notes
- These PowerPoints will review the management of patients on glucocorticoids during the perioperative period.
- Test your knowledge prior to reviewing these slides
- Glucocorticoids can have a variety of effects in the perioperative period. The most common are shown on this slide.
- Surgery is a very potent stimulator of the HPA axis and the amount of cortisol released is dependent on the complexity of the surgery. Normally we make 8-10 mg of cortisol a day. This is increased by surgery up to 200mg for major procedures. It can take several days for cortisol to return to baseline after surgery.
- Not all patients who take corticosteroids have a suppressed HPA axis. Those taking less then 5mg of prednisone daily or less than 10 mg every other day should have a nonsuppressed HPA axis as should those on any dose of steroids for less than 3 weeks. In these patients no additional perioperative glucocorticoid is needed. Patients can just be continued on their normal daily dose of steroids in the perioperative period. They should be monitored for any hemodynamic instability.
- Patients on more than 20mg a day of prednisone for more than 3 weeks and those with clinical evidence of Cushing’s syndrome likely have a suppressed HPA axis and will need supplemental perioperative glucocorticoid coverage. The image on this slide shows the manifestations of Cushing’s syndrome.
- In some patients it will be unclear what their HPA axis function is. Patients on >5 but less than 20 mg prednisone for over 3 weeks or multiple courses of prednisone during the year or those who take them at night could all have suppressed HPA axis function. Several groups also deserve mention including those on high dose inhaled corticosteroids, high potency topical steroids, and those who have received multiple injections of steroids could have suppressed HPA axis function. All these patients should undergo preoperative testing of HPA axis function as discussed on the next slide. If their HPA axis is suppressed then supplemental glucocorticoids should be given perioperatively.
- Patients with unknown HPA axis function should undergo preoperative HPA axis evaluation. The first step is to assess a 8am serum cortisol. If the cortisol is < 5mcg/dl the HPA axis is suppressed. If the cortisol is greater than 10 mcg/dl the HPA axis is fine. If the cortisol is between 5 and 10 mcg/dl further testing with an ACTH stimulation test is needed. An adequate response (meaning intact HPA axis function) is a cortisol > 18 mcg/dl 30 min after injecting 250 mcg of ACTH. If cortisol is less than 18 mcg/dl then the HPA axis is suppressed.
- Patients with a suppressed HPA axis will require supplemental glucocorticoid during the perioperative period except for minor procedures. In all cases they should receive their usual morning dose of steroids plus the supplemental dose as outlined above.
- This patient would fall into the unknown HPA axis suppression category because he has received multiple week to 10 day courses of prednisone greater than 5-20 mg but for less than 3 weeks at a time but total duration is greater than 3 weeks. It is prudent to test his HPA axis function and to then provide supplemental glucocorticoids if he is found to have a suppressed HPA axis. C and D would be incorrect because he does not have a known suppressed HPA axis. Since this patient is undergoing a moderate stress procedure he would require 50 mg of hydrocortisone IV followed by 25 mg for 3 doses.