Steroid Management in Adult Patients with Adrenal Insufficiency Undergoing Surgery/Procedures/Labour

Publication: 08/06/2020  --
Last review: 01/01/1900  
Next review: 08/06/2023  
Clinical Guideline
CURRENT 
ID: 6471 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Steroid Management in Adult Patients with Adrenal Insufficiency Undergoing Surgery/Procedures/Labour

Summary of Guideline

See tables in Management section

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Aims

To improve the management of adult patients with adrenal insufficiency undergoing surgery, invasive procedures or labour.

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Objectives

To provide evidence-based recommendations for appropriate steroid cover in adult patients with adrenal insufficiency undergoing surgery, invasive procedures or labour.
To prevent adrenal crisis in adult patients with adrenal insufficiency undergoing surgery, invasive procedures or labour.

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Background

Adrenal crisis has been reported in patients with adrenal insufficiency who have not received appropriate steroid cover during surgery1,2. Surgical stress results in transient increase in endogenous cortisol production by 5-folds and 15-folds the normal secretion in minor and major surgery, respectively3.
Therefore, it is important that all patients with known adrenal insufficiency receive appropriate glucocorticoid cover during period of surgical or procedural stress.

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Diagnosis:

This guideline applies to:

  1. All adult patients with known adrenal insufficiency (primary or secondary)
  2. All adult patients on long-term steroid therapy sufficient to suppress hypothalamo-pituitary-adrenal axis4
    1. Any patient on prednisolone >5 mg/day (or its equivalent - see table 1) for more than 3 weeks (unless adrenal insufficiency has been formally excluded by Short Synacthen Test).
    2. Any patient on glucocorticoids who has clinical features of iatrogenic Cushing’s syndrome.

Table 1. Corticosteroid Dose Equivalents5

Steroid

Equivalent dose

Prednisolone

5 mg

Prednisone

5 mg

Hydrocortisone

20 mg

Dexamethasone

0.75 mg

Methylprednisolone

4 mg

Triamcinolone

4 mg

Betamethasone

0.6 mg

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Management

General Guidance:

  1. For any nil-by-mouth regimen, give intravenous sodium chloride 0.9% infusion (e.g. 1L/8h if >50kg) to prevent dehydration and maintain mineralcorticoid stability in primary adrenal insufficiency. IV sodium chloride 0.9% volume should be tailored to individual circumstances with special caution in patients at risk of fluid overload (e.g. heart failure or renal failure).
  2. Hydrocortisone bolus should be administered slowly (see Trust monograph) to prevent vascular damage.
  3. Continuous IV hydrocortisone infusion is preferable to 6 hourly IM or IV injections as it provides more stable cover.
  4. Preparation of Hydrocortisone infusion:
    • LTHT has 2 forms of hydrocortisone: Hydrocortisone sodium succinate (Solu-Cortef) and Hydrocortisone sodium phosphate.
    • Both forms are suitable for 24-hour infusion.
    • Prepare the infusion by diluting 200 mg of hydrocortisone in at least 200 ml of glucose 5% or sodium chloride 0.9%.
  5. Patients taking CYP-3A4 inducers (e.g. phenytoin, carbamazepine, rifampicin) should always be placed on continuous IV infusion cover to avoid rapid decompensation.
  6. Monitor electrolytes and blood pressure post-operatively for all procedures requiring parenteral steroid cover. If the patient becomes hypotensive, drowsy, or peripherally shut down, manage as adrenal crisis by giving hydrocortisone 100mg IV (or IM) bolus immediately followed by continuous IV infusion 200mg/24hour.
  7. If any post-operative complications arise (e.g. infection), delay the return to normal oral steroid dosage.
  8. Contact endocrinology registrar (bleep 4710) if further advice is needed.

Patients undergoing surgery

Type of Surgery

Pre-operative and intra-operative dose

Post-operative dose

Major Surgery with long-recovery time
(e.g. cardiac surgery, major bowel surgery, procedures requiring
stay in ICU)

Hydrocortisone 100 mg IV (or IM) just before anaesthesia followed by either:

  • Hydrocortisone continuous IV infusion of 200 mg/24 hour Or
  • Hydrocortisone 50 mg IV (or IM) every 6 hours

Immediate Post-operative:
Continue parenteral hydrocortisone (50 mg IV 6 hourly Or continuous IV infusion 200mg/24 hour).
Once patient is well with no acute infections, able to eat and drink, and discharged from ICU:
Double usual oral steroid dose for 48 hours.
Then return to normal oral steroid dose.

Major surgery with rapid recovery
(e.g. caesarean section, joint replacement)

Hydrocortisone 100 mg IV (or IM) just before anaesthesia followed by either:

  • Hydrocortisone continuous IV infusion of 200 mg/24 hour Or
  • Hydrocortisone 50 mg IV (or IM) every 6 hours

Immediate Post-operative:
Continue parenteral hydrocortisone (50 mg IV 6 hourly Or continuous IV infusion 200mg/24 hour) for 24-48 hours
Once patient is well, and able to eat and drink:
Double usual oral steroid dose for 24-48 hours.
Then return to normal oral steroid dose.

Minor surgery
(e.g. cataract surgery, hernia repairs, laparoscopy with local anaesthetic)

Hydrocortisone 100 mg IM/IV just before anaesthesia.

Double usual oral steroid dose for 24 hours.
Then return to normal oral steroid dose

Minor procedure
(e.g. skin mole removal with local anaesthetic)

Take additional oral dose (e.g. hydrocortisone 10-20 mg PO) 1 hour before procedure

Take a further extra dose (e.g. hydrocortisone 10 mg PO) 1 hour after the procedure.
Then return to normal oral steroid dose.

Labour and vaginal birth

  • At onset of active labour (cervical dilation >4cm): give hydrocortisone 100 mg IV (or IM) followed by either: Hydrocortisone 50 mg IV (or IM) every 6 hours OR Hydrocortisone continuous IV infusion 200 mg/24 hour until delivery.
  • After Delivery: double usual oral steroid dose for 24-48 hours then return to normal steroid oral dose (if well)

Patients undergoing invasive procedures

Type of procedure

Pre-procedure

Post-procedure

Invasive bowel procedures requiring laxatives
e.g. colonoscopy, barium enema

  • Hospital admission overnight.
  • Give IV fluids and hydrocortisone 100 mg IM/IV during preparation.
  • Give hydrocortisone 100mg IM/IV at commencement of procedure.

Double usual oral steroid dose for 24 hours.
Then return to normal oral steroid dose

Other invasive procedures
e.g. OGD

Hydrocortisone 100 mg IM/IV just before commencing procedure.

Double usual oral steroid dose for 24 hours.
Then return to normal oral steroid dose

Patients undergoing dental surgery/procedure

Type of procedure

Pre-operative

Post-operative

Major dental surgery
e.g. Need for general anaesthetic / Complex dental extraction

Hydrocortisone 100 mg IM/IV just before anaesthesia

Double usual oral steroid dose for 24 hours.
Then return to normal oral steroid dose

Minor dental surgery
e.g. Local anaesthetic / Root canal work / Routine dental extraction

Double oral dose of steroid (e.g. take hydrocortisone 20 mg PO) 1 hour prior to surgery

Double usual oral steroid dose for 24 hours.
Then return to normal steroid oral dose

Minor dental procedure
e.g. Replace filling, scale and polish

Take an extra oral dose (e.g. hydrocortisone 10-20mg PO) 1 hour prior to procedure

An extra oral steroid dose where any hypoadrenal symptoms occur afterwards.
Then return to normal steroid dose

Provenance

Record: 6471
Objective:

To provide evidence-based recommendations for appropriate steroid cover in adult patients with adrenal insufficiency undergoing surgery, invasive procedures or labour.
To prevent adrenal crisis in adult patients with adrenal insufficiency undergoing surgery, invasive procedures or labour.

Clinical condition:
Target patient group:
Target professional group(s): Pharmacists
Secondary Care Doctors
Adapted from:

Evidence base

These recommendations are based on experts opinion (Level of evidence C) from guidelines developed by UK Addison’s disease self-help group and physicians of the Addison’s disease clinical advisory panel; https://www.addisons.org.uk/files/file/4-adshg-surgical-guidelines (Accessed online on 20th January 2019). These guidelines were also endorsed by European expert consensus statement in:

Husebye, E. S. et al. Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. Journal of Internal Medicine 275, 104–115 (2014).

Other references:

  1. Fraser, C. G., Preuss, F. S. & Bigford, W. D. Adrenal atrophy and irreversible shock associated with cortisone therapy. JAMA 149, 1542–1543 (1952).
  2. D’Silva, C., Watson, D. & Ngaage, D. A strategy for management of intraoperative Addisonian crisis during coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 14, 481–482 (2012).
  3. Liu, M. M., Reidy, A. B., Saatee, S. & Collard, C. D. Perioperative Steroid ManagementApproaches Based on Current Evidence. Anesthes 127, 166–172 (2017).
  4. Hamrahian, A., Roman, S. & Milan, S. The management of the surgical patient taking glucocorticoids. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on 20th January 2019)
  5. Farinde A. 2019 Apr 18. Corticosteroid Dose Equivalents . [accessed 2019 Sep 25]. https://emedicine.medscape.com/article/2172042-overview.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

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