Issues for surgery
For suppression of inflammatory and allergic/autoimmune disorder (including ulcerative colitis, Crohn’s disease, asthma, chronic obstructive pulmonary disease, rheumatoid arthritis, polymyalgia rheumatica, giant cell [temporal] arteritis, polyarteritis nodosa, myasthenia gravis etc.) – increased risk of disease relapse if omitted.
For prophylaxis of transplant rejection – increased risk of rejection if omitted.
Increased risk of acute adrenal insufficiency or Addisonian crisis (e.g. severe hypotension, tiredness and weakness, confusion, psychosis, tachycardia) if omitted – see Further Information.
For cerebral oedema associated with malignancy – increased risk of worsening cerebral oedema if omitted.
For neuropathic postural hypotension (fludrocortisone) – increased risk of severe hypotension if omitted.
Increased risk of infection (sometimes with atypical presentation) if continued, especially in patients on prolonged courses.
Advice in the perioperative period
Elective and emergency surgery
Continue.
Patients should receive their usual pre-operative dose of steroids on the day of surgery. Also see under Addison’s Disease / Primary adrenal insufficiency below.
Abrupt withdrawal should be avoided in patients who have received systemic corticosteroids at the equivalent dose of prednisolone ≥ 10mg for longer than 3 weeks (see Further information). Refer to the British National Formulary (BNF) ‘Equivalent anti-inflammatory doses of corticosteroids’.
Inform anaesthetist on the day of surgery of use of systemic corticosteroids at the equivalent dose of prednisolone ≥ 10mg daily (including use within the last 3 months).
Steroid-dependent patients should be given ‘first-on-the-list’ status to minimise the risk of dehydration.
Addison’s disease/Primary adrenal insufficiency
Consult with the patient’s endocrinologist prior to surgery where possible.
Consider the need to increase the dose of corticosteroid or take an additional dose prior to procedure – consult the guidance available from www.addisons.org.uk/surgery.
Perioperative considerations
See also Further information.
Consideration should be given to administration of intravenous (IV) hydrocortisone perioperatively for corticosteroid replacement. This will be based on the patient’s risk of adrenal suppression (i.e. dose and duration of corticosteroid therapy) and surgical complexity and stress.
Rheumatology patients
For patients receiving steroid therapy for rheumatology indications – steroid exposure should be minimised prior to surgical procedures, and increases in steroid dose to prevent adrenal insufficiency are not routinely required.
Post-operative advice
Recommence the patient’s usual corticosteroid dose post-operatively, unless an increased dose is clinically indicated (e.g. in Addison’s disease / primary adrenal insufficiency patients – consult the guidance available from www.addisons.org.uk/surgery). Return to normal dose should occur once the patient is stable (e.g. no signs of post-operative infection).
Monitor fluid status, electrolytes, blood pressure and blood glucose post-operatively.
If patients are unable to resume their usual oral medication post-operatively, supplementation with IV hydrocortisone can be considered.
Care is required when considering systemic corticosteroids in patients with recent intestinal anastomoses as administration may lead to anastomotic failure.
Patients undergoing adrenal/pituitary surgery
Patients undergoing adrenal surgery due to Cushing’s disease, cortisol-producing tumours or pituitary tumours, may need to take post-operative corticosteroid medication. The drug, dose, route, frequency and duration should be discussed with the patient’s endocrinologist.
Interactions with common anaesthetic agents
Neuromuscular blocking drugs (NMBDs)
The use of corticosteroids and depolarising or non-depolarising NMBDs can result in prolonged relaxation and acute myopathy, particularly with prolonged use of high-dose corticosteroids. Conversely, an antagonism of the neuromuscular effect has also been seen, although the clinical relevance of the antagonist effect is probably limited. Bear the potential interaction in mind and be alert for the need to increase the dosage of NMBD if necessary.
Interactions with other common medicines used in the perioperative period
Ondansetron
Corticosteroids may cause hypokalaemia, increasing the risk of torsades de pointes, which might be additive with the effects of ondansetron. This is an effective combination for post-operative nausea and vomiting (PONV) prevention and concomitant use is common without adverse effect. Consider the risk with continued post-operative use of this combination. Monitor serum potassium level.
Non-steroidal anti-inflammatory drugs (NSAIDs)
There may be an increased incidence of gastrointestinal bleeding and ulceration when corticosteroids are given with NSAIDs. Consider gastroprotection with either a proton-pump inhibitor or histamine-H2 antagonist if concomitant use of NSAID and corticosteroid is required.
Further information
Adrenal suppression, perioperative stress and corticosteroid replacement
During prolonged therapy with systemic corticosteroids, adrenal atrophy develops. Abrupt withdrawal can lead to acute adrenal insufficiency, hypotension, or death. To compensate for a diminished adrenocortical response, patients undergoing a surgical procedure may require temporary increase in corticosteroid dose, or if already stopped, a temporary reintroduction of corticosteroid treatment. Adrenal suppression can last for a year or more after stopping treatment. The suppressive action of corticosteroid on cortisol secretion is least when it is given as a single dose in the morning.
Current evidence on the necessity of administering perioperative stress-dose steroids for patients with suspected secondary adrenal insufficiency is inadequate to either support or refute this practice. If adrenal insufficiency is a clinical concern, corticosteroid replacement appears to carry minimal risk compared with the risk of adrenal crisis.
Hydrocortisone is the drug of choice for stress and rescue dose steroid coverage. In secondary adrenal insufficiency, the problem is a glucocorticoid deficiency (as opposed to a mineralocorticoid insufficiency). Furthermore, the mineralocorticoid activity of a corticosteroid may result in result in a dose-dependent oedema/fluid retention and hypokalaemia. Where doses greater than 100mg IV hydrocortisone are required, consideration may be given to switching to methylprednisolone due to it having a higher glucocorticoid to mineralocorticoid activity ratio.
References
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Ledingham J et al. Rheumatology Guidelines. The British Society of Rheumatology and British Health Professionals in Rheumatology. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs (2017). www.rheumatology.oxfordjournals.org.
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