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Since the 1940s synthetic corticosteroids (or steroids) have been developed for their anti-inflammatory and immunomodulatory effects. Patients on steroids who present for surgery may be at increased risk of complications because of:
- The adrenal suppression caused by steroid therapy. This often poses the greatest risk and deserves particular attention. It is important for patients to be educated about the risk. Steroid cards should be carried by patients taking steroids.
- The disease or condition which required them to take steroids. Corticosteroids are used in a wide variety of conditions. Some of these may also have attached risks for anaesthesia (those for example affecting lungs, neck joints or drug metabolism).
- Long-term and other side-effects of steroid therapy. These include:
There are preoperative, perioperative and postoperative factors to be considered when assessing and managing these risks.
The risk of adrenal suppression
In normal healthy patients there is a prompt secretion of cortisol with the onset of surgery and secretion remains elevated for several days after surgery. Glucocorticoids are not stored and must be synthesised when required - for example, during and after surgery. This response depends on the hypothalamopituitary axis which may be suppressed or unresponsive to stress when steroids have been taken. Failure of cortisol secretion may result in the circulatory collapse and hypotension characteristic of a hypoadrenal or 'Addisonian' crisis.
- Preoperative considerations:
- How much steroid has been taken and for how long? The degree of adrenal suppression depends on the dose and duration of steroid treatment. However the integrity of the adrenal response is not routinely tested and steroid cover or supplements are given according to the surgical stimulus (minor, moderate and major surgery).
- Dosages of less than 5 mg prednisolone per day are not significant and no steroid cover is required.
- 10 mg/day or more of prednisolone (or equivalent) is generally taken as the threshold dose for 'steroid cover'.
- Steroid cover is required if taken within three months of the surgery. This is because adrenal suppression can occur after only a week and may take as long as three months to recover.
- Perioperative considerations:
- Normal cortisol secretion is about 30 mg/day. The normal rise in plasma adrenocorticotrophic hormone (ACTH) and hence cortisol is in response to the severity of surgery. The adrenals are capable of secreting about 300 mg/day (equivalent to about 75 mg of prednisolone) but output rarely exceeds 150 mg of cortisol/day even in response to major surgery.
- Postoperative considerations:
This should focus on the history of steroid usage, routine examination (including blood pressure) and basic investigations including:
- Serum and urinary cortisol.
- Short synacthen test (SST) - more popular but interpret with care.
- Insulin tolerance test.
- CRH measurement.
It is useful to summarise who should receive steroid cover for surgery (and during major illness):
- Patients on corticosteroids at a dose of 10 mg or more of prednisolone (or equivalent) daily (equivalent to betamethasone 1.6 mg, dexamethasone 1.6 mg, hydrocortisone 40 mg, methylprednisolone 8 mg daily).
- Patients who have received corticosteroids 10 mg daily within the three months preceding surgery.
- Patients on high-dose inhaled corticosteroids (for example beclometasone 1.5 mg a day).
- Patients who stopped their steroids more than three months ago or who are taking 5 mg or less require no steroid cover.
Perioperative steroid cover
Note that infusion is now preferred to bolus (this avoids excessive doses of steroid with possible complications). Historically, doses were even higher; further revision of doses may be recommended with further research but, for the moment, empirical recommendations are:
- Minor surgery - 25 mg hydrocortisone at induction of anaesthesia and then resume normal medication postoperatively.
- Moderate surgery - usual dose of steroids preoperatively and then 25 mg of hydrocortisone intravenously (IV) at induction, followed by 25 mg IV every 8 hours for 24 hours. Usual preoperative dose is then continued.
- Major surgery - usual dose of steroids preoperatively, then a bigger 50 mg of hydrocortisone IV at induction, followed by 50 mg IV every 8 hours for 48-72 hours. Continue this infusion until the patient has started light eating, then restart the normal preoperative dose.
Remember that patients receiving <10 mg of prednisolone or equivalent do not need steroid cover but should continue with their usual maintenance steroid dosage. Patients on long-term steroids do not require supplementary steroid cover for routine dentistry or minor surgical procedures under local anaesthesia.
The risk of underlying disease
There is a wide range of diseases for which corticosteroid treatment is commonly used. It is important to remember that these conditions may also carry risk for both anaesthesia and surgery. Examples of conditions likely to have a consequence for surgery and anaesthesia include:
- Rheumatoid arthritis.
- Idiopathic thrombocytopenic purpura.
- Cerebral oedema.
- Malignancies and chemotherapy.
These conditions should be fully assessed preoperatively.
The risks of long-term steroid treatment
There are many risks associated with long- term steroid treatment and these should be borne in mind preoperatively, perioperatively and postoperatively.
Further reading & references
- Jabbour SA; Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-7.
- Hahner S, Allolio B; Management of adrenal insufficiency in different clinical settings. Expert Opin Pharmacother. 2005 Nov;6(14):2407-17.
- LaRochelle GE Jr, LaRochelle AG, Ratner RE, et al; Recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients with rheumatic diseases receiving low-dose prednisone. Am J Med. 1993 Sep;95(3):258-64.
- Milde AS, Bottiger BW, Morcos M; Adrenal cortex and steroids. Supplementary therapy in the perioperative phase. Anaesthesist. 2005 Jul;54(7):639-54.
- Kihara A, Kasamaki S, Kamano T, et al; Abdominal wound dehiscence in patients receiving long-term steroid treatment. J Int Med Res. 2006 Mar-Apr;34(2):223-30.
- Reynolds RM, Stewart PM, Seckl JR, et al; Assessing the HPA axis in patients with pituitary disease: a UK survey. Clin Endocrinol (Oxf). 2006 Jan;64(1):82-5.
- Gibson N, Ferguson JW; Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature. Br Dent J. 2004 Dec 11;197(11):681-5.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
|Original Author: Dr Richard Draper||Current Version: Dr Gurvinder Rull|
|Last Checked: 22/06/2011||Document ID: 941 Version: 22||© EMIS|