Inadequate control or management of patients on steroids during surgical procedures may heighten the risk of complications. This heightened risk is attributed to the suppression of the hypothalamopituitary axis (HPA axis) induced by steroid therapy. The primary concern lies in adrenal suppression, a consequence of steroid therapy, and demands specific attention. It is crucial to educate patients about the associated risks and stress the importance of carrying their steroid cards.
Additionally, long-term effects and side effects of steroid therapy include hypertension, diabetes mellitus, fatty liver, susceptibility to infection, osteoporosis, avascular necrosis of bone, skin sepsis, and electrolyte disturbances such as hypokalemia and metabolic alkalosis.
Surgery induces a stress response, prompting cortisol secretion. Glucocorticoids, which are not stored but synthesized as needed, become problematic when the HPA axis is suppressed. This may lead to a deficiency in cortisol production, potentially resulting in circulatory collapse and hypotension, characteristic of a hypoadrenal or 'Addisonian' crisis.
Preoperative considerations involve assessing the quantity and duration of steroid use to determine the degree of adrenal suppression. The adrenal response integrity is not routinely tested, and steroid cover or supplements are provided based on the surgical stimulus (minor, moderate, or major surgery). Dosages less than 5 mg prednisolone per day generally do not require cover, while 10 mg/day or more is considered the threshold dose for 'steroid cover,' especially if taken within three months of surgery.
During the perioperative period, normal cortisol secretion is approximately 30 mg/day, with adrenals capable of secreting about 300 mg/day in response to severe surgery. Postoperative considerations involve a normal rise in cortisol secretion lasting about three days. In recent years, reduced doses for steroid cover have been favored to avoid adverse effects.
Preoperative assessment should focus on the history of steroid usage, routine examination, and basic investigations, including FBC, U&Es, blood glucose, and LFTs. Investigations for adrenal suppression are rarely performed but may include serum and urinary cortisol, short synacthen test (SST), insulin tolerance test, and CRH measurement.
Perioperative management applies to patients who received corticosteroids at least 10 mg daily within three months preceding surgery or those on high-dose inhaled corticosteroids. Patients who stopped steroids more than three months ago or take 5 mg or less generally require no steroid cover. Perioperative steroid cover recommendations are outlined based on the hormonal response to surgery, differentiating between minor, moderate, and major procedures.
Patients receiving less than 10 mg of prednisolone or equivalent typically do not need steroid cover but should maintain their usual maintenance steroid dosage. Long-term steroid users generally do not require supplementary steroid cover for routine dentistry or minor surgical procedures under local anesthesia.
Precautions for Steroid Users Undergoing Surgery
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