Perioperative stress-dose steroids

Area of Science:

• Anesthesiology
• Endocrinology
• Surgical Care

Background:

• Perioperative corticosteroid supplementation has been standard practice for patients on long-term steroid therapy for over 60 years.
• Emerging evidence challenges the necessity of supraphysiologic corticosteroid doses in this patient population.
• Current guidelines are based on historical practices rather than robust clinical data.

Purpose of the Study:

• To evaluate the necessity of supraphysiologic corticosteroid doses during the perioperative period for patients on long-term steroid therapy.
• To determine if standard maintenance doses are adequate, thereby reducing potential corticosteroid-related complications.
• To inform clinical practice regarding corticosteroid management in surgical patients.

Main Methods:

• Systematic review of existing literature, including retrospective studies, prospective cohorts, and randomized controlled trials.
• Analysis of data from two small prospective, randomized placebo-controlled trials.
• Inclusion of findings from a prospective primate trial and several systematic reviews.

Main Results:

• Accumulating data suggests that supraphysiologic perioperative corticosteroid doses are not required for patients on long-term exogenous steroid therapy.
• Patients can safely remain on their established baseline maintenance corticosteroid dose.
• Secondary adrenal insufficiency should be considered as a potential cause of unexplained perioperative hypotension.

Conclusions:

• The practice of administering supraphysiologic corticosteroid doses perioperatively is not supported by current evidence.
• Patients on long-term steroid therapy should continue their maintenance dose, with vigilance for adrenal insufficiency.
• Clinical guidelines should be updated to reflect the evidence against routine high-dose perioperative corticosteroid administration.