The patient was on 20 mg of prednisone per day for 5 days as part of the treatment of an asthma exacerbation 3 months ago. He is currently not on steroids. Should the patient receive stress-dose steroids?
Answer:
Patients on chronic steroid therapy may experience hypothalamic-pituitary-adrenal (HPA) axis suppression that can result in decreased cortisol (hydrocortisone) production, a process known as secondary adrenal insufficiency. The concern is that inadequate cortisol production in response to the stress of surgery can manifest as full-blown adrenal crisis in the perioperative period. The anesthesiologist must decide whether to administer stress-dose steroids to mitigate this rare but potentially life-threatening complication of chronic steroid use. However, the decision is not always clear-cut because even the recommendations found in most textbooks are inconsistent and lacking in class A and B evidence. Additionally, there is no universally agreed on dose or duration of exogenous steroids required to cause HPA axis dysfunction, although prednisone 20 mg per day for 2 weeks within the previous 6 months has been cited.
Given this patient’s short duration of prednisone treatment, he should not require administration of stress-dose steroids. However, 100 mg of hydrocortisone intravenous (typical stress-dose for this type of surgery) should be available in the operating room in case hypotension attributable to adrenal insufficiency occurs during surgery.
Another consideration is whether the patient will receive prophylaxis for postoperative nausea/vomiting (PONV) with dexamethasone. Dexamethasone has 30 times glucocorticoid potency of hydrocortisone, so even a modest PONV dose of 4 mg of dexamethasone is equivalent to the usual stress dose of hydrocortisone. Because there is no mineralocorticoid deficiency in secondary adrenal insufficiency, dexamethasone’s absence of mineralocorticoid activity is not an issue.
Reference(s):
- Liu MM, Reidy AB, Saatee S, et al. Perioperative steroid management: approaches based on current evidence. Anesthesiology. 2017;127:166-172.
- Wax DB. One size fits all for stress-dose steroids. Anesthesiology. 2018;128:680-681.
- Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth. 2009;103(suppl 1):i57-i65.