Perioperative steroid therapy: where's the evidence?

Area of Science:

• Endocrinology
• Anesthesiology
• Surgical Care

Background:

• Chronic glucocorticoid therapy is widely used for various conditions.
• Perioperative management of these patients requires careful consideration of adrenal function.
• Adrenal suppression can lead to life-threatening adrenal insufficiency during surgical stress.

Purpose of the Study:

• To review historical and current evidence on adrenal suppression in patients on chronic glucocorticoid therapy.
• To discuss current recommendations for perioperative stress dose steroid administration.
• To evaluate the incidence and implications of perioperative adrenal insufficiency.

Main Methods:

• Comprehensive literature review of historical and contemporary studies.
• Analysis of evidence regarding perioperative adrenal insufficiency incidence.
• Evaluation of studies on withholding vs. administering stress dose steroids.
• Synthesis of current clinical guidelines and expert recommendations.

Main Results:

• Evidence indicates a low incidence of perioperative adrenal insufficiency in patients on chronic glucocorticoid therapy.
• Recent studies suggest no significant difference in survival or hemodynamic outcomes when withholding perioperative stress steroids.
• These findings are limited by study size and may not be universally applicable.

Conclusions:

• Current recommendations for perioperative stress dose steroids are guided by maintenance steroid dose and duration.
• Patients must continue their regular daily steroid dose preoperatively, irrespective of prior treatment.
• Additional stress dose steroid administration should be individualized based on adrenal suppression risk and surgical complexity.