Requirement of Perioperative Stress Doses of Corticosteroids: A Systematic Review of the Literature
Marik PE, Varon J
Arch Surg. 2008;143:1222-1226
Study Summary
This descriptive review article aims to determine the role of perioperative stress-dose corticosteroids in persons receiving long-term corticosteroid therapy who undergo surgery. The 2 authors independently searched the literature for randomized, controlled trials and cohort studies relevant to the topic. They extracted data regarding surgical procedures performed, corticosteroid doses prescribed, hypothalamic-pituitary-adrenal (HPA) axis testing, and hemodynamic outcomes.
The authors found 9 articles, describing 315 patients, that met the inclusion criteria; 2 studies were randomized, placebo-controlled trials. Overall, the authors report that if patients continued their usual outpatient regimen of corticosteroids through the perioperative period (even major surgery), risk for adverse hemodynamic outcomes was low. In patients with corticosteroid treatment for nonprimary HPA axis failure, preoperative testing for adrenal response often revealed below-normal endogenous corticosteroid production. However, this finding did not predict adverse outcomes, perhaps because of increased endogenous steroid production in response to surgical stress.
Patients with primary failure of the HPA axis (such as Addison’s disease) did require stress-dose perioperative steroids, perhaps because they lacked the ability to increase endogenous corticosteroid production. If stress-dose corticosteroids are needed, the authors recommend a dose of hydrocortisone 50 mg intravenously intraoperatively, then dosing every 8 hours for 48-72 hours postoperatively.
Of interest, the authors mention in their discussion that the agent etomidate, which is used in induction of anesthesia, inhibits endogenous corticosteroid production. In patients given this drug, one may consider using stress-dose steroids, as endogenous corticosteroid production may be compromised; however, none of the studies reviewed included use of this agent.
Viewpoint
Rheumatologists and other healthcare providers are often asked to provide guidance regarding the perioperative use of corticosteroids. In an informal poll of my rheumatology colleagues, most usually recommend perioperative stress-dose corticosteroids if their patient is receiving these agents over the long term, although all of my colleagues state that they believe that the data guiding this decision are limited.
Certainly we need more well-done trials to help us better understand the issues surrounding perioperative corticosteroid use, but I think this review serves as a good reminder that, with some exceptions (such as primary HPA failure and perhaps etomidate use), we may not need to use perioperative stress-dose corticosteroids as often as we do.
Continuing the usual daily dose of corticosteroids in the perioperative period (perhaps given intravenously if oral intake is precluded) with awareness and careful monitoring of hemodynamic status may be adequate for most patients, helping us to avoid the increased financial cost of stress-dose regimens and the possible adverse outcomes of higher corticosteroid doses.
Abstract