Perioperative stress-dose steroids

Supraphysiologic corticosteroid doses have routinely been considered the perioperative standard of care over the past six decades for patients on long-term steroid therapy. However, the accumulation of data over this period is beginning to suggest that such a practice may not be necessary. The majority of these studies are retrospective reviews or small prospective cohorts, but there are two small prospective, randomized placebo-controlled trials, one prospective primate trial, and several systematic reviews addressing the issue. Based on this developing evidence, patients on long-term exogenous steroids do not require high-dose perioperative corticosteroids and should instead remain on their baseline maintenance dose, with the understanding that secondary adrenal insufficiency should be considered for unexplained perioperative hypotension in these patients.