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How should steroids be dosed in the perioperative period and are stress dose steroids needed for all individuals who are taking or who have received recent steroids?
Data suggests that many patients on corticosteroids may not require perioperative stress-dosing, especially if the patient is undergoing a minor procedure and is monitored closely in the perioperative period. The 2017 ACR/AAHKS guidelines on perioperative management for elective total knee or hip arthroplasty recommend that the current daily dose of steroid be continued throughout the operative period, without routine stress-dosing. For other types of major surgery or physiologic stress (e.g., serious infections or trauma), some providers may elect to provide perioperative stress-dose steroids due to the potential life-threatening complications of adrenal insufficiency. In this setting, given the high cost of the ACTH stimulation test (>$200) and perceived low risk of short-term corticosteroid use, treatment is often given empirically without formal testing. Of note, the anesthetic agent, etomidate, may interfere with adrenal corticosteroid synthesis; as such, if this agent is used for anesthesia, stress-dose steroids should be considered regardless of the level of surgical risk.
In patients receiving stress-dose steroids, tapering back to the baseline corticosteroid dose should occur within 48 to 72 hours if possible to avoid increased risk of infection and/or problems with wound healing. Elaborate tapering schedules are not required unless postoperative complications prolong stress after surgery. In general, patients on oral steroids preoperatively may typically resume their normal daily dose once stable postoperatively and taking oral medications well. Hydrocortisone is considered the corticosteroid of choice for stress-dose regimens because it has a rapid onset of action compared with other agents. There is clinical variation in the literature regarding the dose and duration of stress-dose steroid regimens;
The below table outlines one reasonable approach.
Perioperative Regimens for Stress-Dose Corticosteroid Administration
| Level of Surgical Stress | Surgical Procedure | Stress-Dose Steroids |
|---|---|---|
| Superficial procedure | Skin biopsy | Continue daily dose of corticosteroids |
| Minor | Procedures under local anesthesia and <1 hour Colonoscopy, cataract surgery, carpal tunnel release, tenosynovectomy, knee arthroscopy Most minor podiatry/orthopedic foot procedures (hammer toe correction, toe fusion) | Continue daily dose of corticosteroids Hydrocortisone on call to OR for urgent use if necessary |
| Moderate a | Unilateral total joint replacement Complex foot reconstruction Lower extremity vascular surgery Uncomplicated appendectomy Gallbladder removal | Hydrocortisone 50–100 mg IV intraoperatively in OR, then 50 mg IV every 8 hours for 24 hours. On the second postoperative day, hydrocortisone may be tapered over an additional 24 hours or preoperative daily oral dosing may be resumed. |
| Major | Multiple trauma Colon resection, bilateral joint replacement, revision arthroplasty, multiple level spinal fusion Any surgery requiring cardiopulmonary bypass | Hydrocortisone 100 mg IV intraoperatively in OR, then 100 mg IV every 8 hours for 24 hours, then 50 mg IV every 8 hours for the next 24 hours, then resume the preoperative daily dose on third postoperative day |
IV, Intravenous; OR, operating room.
- Caveats:
- (1)Patients must be monitored carefully for signs of adrenal insufficiency (hypotension) in the perioperative period and stress-dosing may need to be adjusted.
- (2)Resumption of daily oral dosing of corticosteroids is dependent on oral intake postoperatively and may be delayed if nil per os, also called as nothing by mouth, status is prolonged (e.g., with abdominal surgery, nausea).
- (3)If postoperative hypotension develops, patients should be assessed for etiologies other than adrenal insufficiency including volume depletion, cardiovascular disease, pulmonary embolus, and infection.
a May consider continuing preoperative daily oral dose rather than stress-dose regimen.
