Hypotension during and after operation in glucocorticoid-treated patients

Perioperative Evaluation and Management of Patients on Glucocorticoids

Myriad questions regarding perioperative management of patients on glucocorticoids (GCs) continue to be debated including which patients are at risk for adrenal insufficiency (AI), what is the correct dose and duration of supplemental GCs, or are they necessary for everyone? These questions remain partly unanswered due to the heterogeneity and low quality of data, studies with small sample sizes, and the limited number of randomized trials. To date, we know that although all routes of GC administration can result in hypothalamic-pituitary-adrenal (HPA) axis suppression, perioperative adrenal crisis is rare. Correlation between biochemical testing for AI and clinical events is lacking. Some of the current perioperative management recommendations based on daily GC dose and duration of therapy may be difficult to follow in clinical practice. The prospective and retrospective studies consistently report that continuing the daily dose of GCs perioperatively is not associated with a higher risk for adrenal crises in patients with GC-induced AI. Considering that oral GC intake may be unreliable in the early postoperative period, providing the daily GC plus a short course of IV hydrocortisone 25 to 100 mg per day based on the degree of surgical stress seems reasonable. In patients who have stopped GC therapy before surgery, careful assessment of the HPA axis is necessary to avoid an adrenal crisis. In conclusion, our literature review indicates that lower doses and shorter duration of supplemental GCs perioperatively are sufficient to maintain homeostasis. We emphasize the need for well-designed randomized studies on this frequently encountered clinical scenario.

Perioperative corticosteroid management for patients with inflammatory bowel disease

Guidelines on the appropriate use of perioperative steroids in patients with inflammatory bowel disease (IBD) are lacking. As a result, corticosteroid supplementation during and after colorectal surgery procedures has been shown to be highly variable. A clearer understanding of the indications for perioperative corticosteroid administration relative to preoperative corticosteroid dosing and duration of therapy is essential. In this review, we outline the basic tenets of the hypothalamic-pituitary-adrenal (HPA) axis and its normal response to stress, describe how corticosteroid use is thought to affect this system, and provide an overview of the currently available data on perioperative corticosteroid supplementation including the limited evidence pertaining to patients with inflammatory bowel disease. Based on currently existing data, we define "adrenal suppression," and propose a patient-based approach to perioperative corticosteroid management in the inflammatory bowel disease population based on an individual's historical use of corticosteroids, the type of surgery they are undergoing, and HPA axis testing when applicable. Patients without adrenal suppression (<5 mg prednisone per day) do not require extra corticosteroid supplementation in the perioperative period; patients with adrenal suppression (>20 mg prednisone per day) should be treated with additional perioperative corticosteroid coverage above their baseline home regimen; and patients with unclear HPA axis function (>5 and <20 mg prednisone per day) should undergo preoperative HPA axis testing to determine the best management practices. The proposed management algorithm attempts to balance the risks of adrenal insufficiency and immunosuppression.

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.

How to manage perioperative endocrine insufficiency

Patients with endocrinopathies frequently present to the operating room. Although many of these disorders are managed on a chronic basis, patients may have acute changes in the perioperative period that, if left unrecognized, can have a negative effect on perioperative morbidity and mortality. It is imperative that anesthesiologists understand the implications of the surgical stress response on hormonal flux. This article focuses on the 4 most commonly encountered endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Specific challenges pertaining to patients with pheochromocytoma are also discussed.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Surgery in the patient with endocrine dysfunction

Patients with preoperative endocrinopathies represent a particular challenge not only to anesthesiologists but also to surgeons and perioperative clinicians. The "endocrine axis" is complex and has multiple feedback loops, some of which are endocrine and paracrine related, and others that are strongly influenced by the surgical stress response. Familiarity with several of the common endocrinopathies facilitates management in the perioperative period. This article focuses on 4 of the most common endocrinopathies: diabetes mellitus, hyperthyroidism, hypothyroidism, and adrenal insufficiency. Perioperative challenges in patients presenting with pheochromocytoma are also discussed.

Perioperative glucocorticosteroid supplementation is not supported by evidence

Ever since the first descriptions of adrenal insufficiency following exogenous supplementation physicians dread to abolish perioperative glucocorticosteroid supplementation. Now, 55 years after the first publications we can challenge those first reports. However, these cases have resulted in the supplementation of supraphysiological doses of glucocorticosteroids to patients that use exogenous corticosteroids: the so-called perioperative glucocorticosteroid supplementation or "(gluco)corticosteroid stress scheme". It is very questionable whether a dose that exceeds the normal daily production of 5.7 mg cortisol per square meter of body surface area is necessary to prevent perioperative hypotension. Retrospective, prospective and randomised studies, though all methodologically flawed, are discussed and show that continuation of the "basal" amount of glucocorticosteroids is sufficient to counterbalance surgical stress. The current and rather defensive strategy of perioperative supraphysiological glucocorticosteroid supplementation is not embedded in medical evidence. Additionally, high doses of glucocorticosteroids have disadvantages that should not be ignored.

Mean arterial pressure and systolic blood pressure for detection of hypotension during hemapheresis: implications for patients with baseline hypertension

Mean arterial pressure (MAP) has been characterized as a more sensitive and physiologically appropriate hemodynamic parameter in the detection of hemapheresis-related hypotension, resulting in a much closer correlation with the presence of symptomatic hypotension. Patients were enrolled over a 12-month period and data collected on any previous diagnosis of hypertension, antihypertensive therapy used, indication for apheresis, age decile, and gender. Baseline vital signs, any hypotensive signs or symptoms observed, and the patient's vital signs at the time of any hypotensive episode were recorded. Patients were assigned to a subgroup, sensitivity and specificity analysis performed, positive likelihood ratios calculated, receiver operating characteristic curves constructed, and ideal cutoff values identified. The incidence of hypotension among our study population was found to be 6.8%. Over all procedures, systolic blood pressure (SBP) was determined to be a "poor" test for detecting hypotension, while MAP demonstrated a "fair" capacity. A downward normalization was evident in the ideal cutoff value based upon a patient's hypertensive history. The currently accepted SBP less than 80 mmHg cutoff failed to detect hypotensive episodes among baseline hypertensive patients, raising questions about its sensitivity. Based upon physiologic principles and study findings, a MAP-based criterion is preferable in the diagnosis of hypotension during hemapheresis.

Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature

Based to a great extent upon mainly anecdotal case reports and theory, there is a general acceptance that patients on long-term systemic steroid medication should receive supplementary glucocorticoids or "steroid cover" when undergoing certain types of stressful treatment including dentistry. The theoretical basis to this practice is that exogenous steroids suppress adrenal function to an extent that insufficient levels of cortisol can be produced in response to stress, posing the risk of acute adrenal crisis with hypotension and collapse. The purpose of this paper is to review relevant literature and propose clinical guidelines for dental practitioners. Of numerous reported cases of adrenal crisis following procedural interventions, few stand up to critical evaluation. Other reviewers have reached similar conclusions. A number of studies confirm the low likelihood of significant adrenal insufficiency even following major surgical procedures. Various authors have suggested modified guidelines for management of patients on steroid medications. Patients on long-term steroid medication do not require supplementary "steroid cover" for routine dentistry, including minor surgical procedures, under local anaesthesia. Patients undergoing general anaesthesia for surgical procedures may require supplementary steroids dependent upon the dose of steroid and duration of treatment.

Perioperative management of patients treated with glucocorticoids

HPA suppression is a common consequence of glucocorticoid therapy, whereas overt secondary adrenal insufficiency is a rare but life-threatening condition. Prolonged hypotension and a response to adequate doses of a glucocorticoid agent are not reliable ways to assess adrenocortical function. One must also demonstrate plasma cortisol levels that are inappropriately low for the clinical situation. Hypotension in patients previously treated with glucocorticoids is caused by loss of the permissive effect of glucocorticoids on vascular tone, which may be related in turn to enhanced PGI2 production in the absence of glucocorticoids. It is not caused by mineralocorticoid deficiency. Recurrent problems of study design and interpretation have plagued this area of investigation. Any patient who has received a glucocorticoid in doses equivalent to at least 20 mg a day of prednisone for more than 5 days is at risk for HPA suppression. If the doses are closer to but above the physiologic range, 1 month is probably the minimal interval. Recovery from prolonged exposure to high doses of glucocorticoids may take up to 1 year. Pituitary function returns before adrenocortical function. Recovery from short courses of treatment (e.g., 5 days) occurs more rapidly, in about 5 days. Recovery is time-dependent and spontaneous. The rate of recovery is a function of the dose and duration of therapy before tapering is started and while the dose is being reduced. ACTH therapy does not cause adrenocortical suppression but offers no advantage over glucocorticoids, has several disadvantages, and should no longer be used. Patients on alternate day glucocorticoid therapy have some suppression of basal cortisol levels but have normal or nearly normal responses to provocative tests of adrenocortical function. The standard short ACTH stimulation test is a reliable means of assessing adrenocortical function preoperatively. The low dose (1 microgram) short ACTH test is promising but has not been sufficiently well characterized, requires serial dilutions and cannot be recommended at this time. Studies of the physiologic adrenocortical response to surgical stress provide a basis for revised dose recommendations for perioperative coverage in the patient with known or suspected HPA suppression. Recommendations of a multidisciplinary group are presented.

[The necessity for perioperative cortisol substitution. Spontaneous and stimulated ACTH and cortisol secretion during unilateral adrenalectomy for renal cell carcinoma]

Impaired adrenal function during perioperative stress carries the risk of acute cortisol (Cs) deficiency (Addisonian crisis), which may be critical without Cs supplementation. Thus, with evidence of dysfunction of the adrenal glands perioperative substitution is indicated. However, it is unclear whether unilateral adrenalectomy may attenuate the adrenocorticoid response. Glucocorticosteroids are potent agents with several well-known side effects. The purpose of the present study was to evaluate if routine Cs supplementation is justified and necessary in patients undergoing adrenalectomy during nephrectomy for renal-cell cancer.

METHODS

Ten consecutive patients with renal-cell cancer (5 male, 5 female; age 58 +/- 10 years; ASA class I-II) who underwent adrenalectomy with radical nephrectomy were included in this study. None of them had received steroids for at least 5 years prior to the current surgery. Anaesthesia was induced with propofol, fentanyl, and vecuronium and maintained with isoflurane (PetIso: 0.8 +/- 0.3 vol.%) in nitrous oxide (66%) and oxygen. The patients did not receive any Cs treatment perioperatively. Monitoring included heart rate (beats/min), mean arterial pressure (mm Hg), central venous pressure (mm Hg), O2 saturation (%), and body temperature (degrees C, rectal). Plasma analyses included Cs (Cs radioimmunoassay IBL; normal 120-250 ng/ml), adrenocorticotropic hormone (ACTH) (ACTH-II IRMA; normal (10-50 pg/ml), glucose, and electrolytes determined as follows: preoperatively (8 a.m.); 1-6 h (60-min intervals) after surgery; pre-corticotropin-releasing hormone (CRH) (Corticobiss: 2 micrograms/kg i.v.) administration (1st postop. day at 8 a.m. and after 30, 60, 90, and 120 min. The study was completed with plasma analyses on postoperative days 2 and 3 (8 a.m.).

RESULTS

None of the patients showed any clinical signs of plasma parameter of adrenal insufficiency due to the unilateral adrenalectomy. Serum levels (median: 25%/75% percentiles) of Cs (maximum [max.]:253 [217/288] ng/ml) and ACTH (max.:347 ([68/405] pg/ml) were elevated above the normal range postoperatively). After intravenous stimulation with CRH (1st postoperative day), Cs (max.:273 [248/310] ng/ml) and ACTH (max.: 107 ([75/275] pg/ml) were also increased above normal. During postoperative days 2 and 3 (8 a.m.) Cs and ACTH remained in the high-normal range.

CONCLUSIONS

Data from this study indicate that unilateral adrenalectomy was associated with adequate spontaneous Cs secretion by the remaining adrenal gland. Moreover, stimulation with CRH demonstrated adequate reactivity of the pituitary-adrenal axis. None of the patients showed any signs of Cs deficiency by clinical or serum parameters. Therefore, we do not recommend routine Cs supplementation in patients undergoing adrenalectomy during tumor nephrectomy, nevertheless, Cs supplementation remains necessary for patients with primary hypothalamic-pituitary-adrenal dysfunction (Addison's disease) or hyperfunction (Cushing's disease).

A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency

BACKGROUND

Patients treated long-term with supraphysiologic doses of glucocorticoids experience secondary adrenal insufficiency and are routinely given large doses of steroids in the perioperative period to prevent hypotension. Because the dose of steroids required to prevent hypotension is not known, we conducted a randomized, double-blind study to determine whether patients treated long-term with glucocorticoids actually require increased steroids in the perioperative period.

METHODS

Patients who had been taking at least 7.5 mg prednisone daily for several months and had secondary adrenal insufficiency as defined by adrenocorticotropic hormone testing formed the study population. Patients were randomized to two groups. One group received perioperative injections of saline solution alone; the other received perioperative saline solution and cortisol. All patients received their usual daily prednisone dose throughout the study.

RESULTS

Six patients were in the steroid-treated group and 12 were in the saline-treated group. Most subjects underwent major operations such as joint replacements, abdominal operations, and miscellaneous other procedures. Two patients had hypotension, one in each group. Hypotension resolved with volume replacement in both patients. The average pulse rates and blood pressures were similar in both groups during the perioperative period.

CONCLUSIONS

Patients with secondary adrenal insufficiency do not experience hypotension or tachycardia caused by inadequate glucocorticoid levels when given only their daily dose of steroids for surgical procedures.

Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem

OBJECTIVE

The authors review the historical basis for the provision of perioperative glucocorticoid coverage, and detail the evolution in the understanding of the role of the hypothalamic-pituitary-adrenal cortical (HPA) axis in response to physical stressors. New recommendations are proposed for glucocorticoid-dependent patients who require anesthesia and surgery.

SUMMARY BACKGROUND DATA

In 1952, a patient developed surgery-associated adrenal insufficiency as a result of preoperative withdrawal from glucocorticoid therapy. That case report, and one other in the ensuing 12 months, prompted the publication of recommendations for perioperative glucocorticoid coverage, which became the standard of care. The understanding of the role of the HPA axis in the stress response has been subsequently refined; however, recommendations for perioperative glucocorticoid coverage have not been altered in parallel.

METHODS

Studies were identified beginning with the first reports of the physiologic actions of the adrenal glands (1855) and the description and clinical use of cortisone (1930-1993). Studies were selected for review if they were related to or evaluated the provision of stress-related glucocorticoid administration. All clinical studies were evaluated to determine the basis for the provision of perioperative glucocorticoid coverage and the validity of the data used to justify these conclusions.

CONCLUSIONS

Clinical and experimental evidence support the concept that the current amount of perioperative glucocorticoid coverage is excessive and has been based on anecdotal information. New recommendations are proposed which suggest that the amount and duration of glucocorticoid coverage should be determined by: a) the preoperative dose of glucocorticoid taken by the patient, b) the preoperative duration of glucocorticoid administration, and c) the nature and anticipated duration of surgery.