Chapter 11. Patient on Corticosteroids

• Corticosurrenal production under control of the hypothalamic–pituitary axis of:
  • Glucocorticosteroids (cortisol [= hydrocortisone] and corticosterone)
  • Mineralocorticosteroids (aldosterone)
• Basal corticosteroid production in an adult patient = 5–10 mg/m2 per day of cortisol (equivalent to 5–7 mg prednisone or 20–30 mg hydrocortisone for an average adult)
• If extrinsic steroid therapy administered, negative feedback to the hypothalamic–pituitary axis and inhibition of the corticoadrenal production
• In case of stress (such as surgery, disease, physical exertion, pregnancy), the normal protective surge in systemic cortisol will be inhibited, thus putting the patient at risk of acute adrenal insufficiency
• Normal daily secretion of cortisol in the perioperative period (about 72 hours):
  • Minor surgery: 25 mg
  • Moderate surgery: 50–75 mg
  • Major surgery: 100–150 mg
• Stress-dose steroid replacement should be commensurate to the need; if excessive, risk of infectious complications, delayed wound healing, and disturbed metabolic regulation (hyperglycemia)

Corticosteroids as chronic therapy = major reason for adrenal insufficiency.

Even possible for short therapy (5 days) or low dose (5 mg per day of prednisone).

Note that dexamethasone should not be used to replace intrinsic steroid production, as it has no mineralocorticoid effect.

Minor Surgical Stress (e.g., Hand Surgery, Hernia)

Take the usual steroid therapy on the morning of surgery.

Possibly, on induction: 25 mg hydrocortisone IV or 5 mg methylprednisolone IV.

Moderate Surgical Stress (e.g., Hysterectomy, Cholecystectomy)

• Elective surgery: usual corticotherapy on the morning of surgery, 25 mg hydrocortisone IV q8 hours for 48 hours at the most
• Emergency surgery: on induction, 25–50 mg hydrocortisone IV, and then 25–50 mg hydrocortisone IV q8 hours

After surgery, usual therapy or equivalence with hydrocortisone IV q8 hours if unable to take po.

Major Surgical Stress (e.g., Major Trauma, Prolonged Surgery, or Surgery Where There Is Delayed Oral Intake, Such as Esophagectomy, Cardiac Surgery)

• Elective surgery: usual steroid therapy on the morning of surgery, 50 mg hydrocortisone IV on induction, and then 50 mg hydrocortisone IV q8 hours until patient able to resume usual therapy
• Emergency surgery: 100 mg hydrocortisone IV on induction, and then 50 mg hydrocortisone IV q8 hours until patient able to resume usual therapy

Usual treatment: hydrocortisone and fludrocortisone (glucocorticosteroids and mineralocorticosteroids).

• The day before: usual therapy
• The morning of surgery:
  • Premedication with 9-α-fludrocortisone 50 μg po
  • During surgery: hydrocortisone 50 mg IV, and then 10–20 mg/h
• After surgery ...