Perioperative Management of Patients on Steroids Requiring Surgery

Patients with chronic lung disease, inflammatory bowel disease, rheumatoid arthritis, and solid-organ transplantations are often on steroid supplementation either intermittently or chronically. Endogenous steroid use results in decreased adrenocorticotropic hormone secretion by the pituitary gland through negative feedback mechanisms. Over several weeks, this can result in adrenal gland atrophy, eventually leading to secondary adrenal insufficiency. Appropriate management of perioperative glucocorticoid replacement therapy can be challenging, but appropriate replacement is essential to optimize patient outcomes. Insufficient dosing of glucocorticoids during the perioperative period can result in hypotension and even death. Excessive treatment with glucocorticoids decreases wound healing, increases the risk of hyperglycemia, and increases susceptibility to infection. This review covers the historical perspective, the hypothalamic-pituitary-adrenal (HPA) axis, when to suspect an impaired HPA axis, an argument against supraphysiologic glucocorticoid treatment in the perioperative period, the rationale for treating patients with impaired renal function, guidelines for dosing glucocorticoids in the perioperative period, and consulting a specialist. Figures show a clinical algorithm for evaluation and treatment of adrenal insufficiency in the perioperative period and the HPA axis. Tables list steroid conversions and perioperative glucocorticoid treatment recommendations. This review contains 2 highly rendered figures, 2 tables, and 22 references.