Education  |   July 2017
Perioperative Steroid Management: Approaches Based on Current Evidence
Author Notes
  • From the Division of Cardiovascular Anesthesia, Texas Heart Institute, Baylor St. Luke’s Medical Center, Houston, Texas.
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
  • Figure 1 was enhanced by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina.
    Figure 1 was enhanced by Annemarie B. Johnson, C.M.I., Medical Illustrator, Vivo Visuals, Winston-Salem, North Carolina.×
  • Submitted for publication May 15, 2016. Accepted for publication March 2, 2017.
    Submitted for publication May 15, 2016. Accepted for publication March 2, 2017.×
  • Address correspondence to Dr. Liu: Division of Cardiovascular Anesthesia, Texas Heart Institute, Baylor St. Luke’s Medical Center, 6720 Bertner Avenue, MC 1–226, P.O. Box 20345, Houston, Texas 77225-0345. melanieliu329@gmail.com. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Clinical Concepts and Commentary / Cardiovascular Anesthesia / Endocrine and Metabolic Systems
Education   |   July 2017
Perioperative Steroid Management: Approaches Based on Current Evidence
Anesthesiology 7 2017, Vol.127, 166-172. doi:10.1097/ALN.0000000000001659
Anesthesiology 7 2017, Vol.127, 166-172. doi:10.1097/ALN.0000000000001659
CHRONIC steroid therapy is a cornerstone treatment for many common conditions, including inflammatory bowel disease, rheumatologic disease, reactive airway disease, and immunosuppression for transplant recipients. Patients on chronic steroid therapy may develop secondary adrenal insufficiency that can manifest as full-blown adrenal crisis in the perioperative period. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative stress-dose steroids to mitigate this rare but potentially fatal complication of chronic steroid use. In doing so, the patient’s risk for adrenal crisis must be weighed against the risks of unnecessary steroid supplementation. Unfortunately, this decision is not always clear-cut, because even the recommendations found in major textbooks are confusing, inconsistent, and lacking in class A and B evidence (table 1). Despite the lack of standardization and the widespread use of perioperative stress-dose steroids observed in clinical practice, a recent search of the Anesthesia Closed Claims Project database containing 11,247 claim narratives using the terms “stress dose,” “Cushing,” “Addison,” and “adrenal insufficiency” revealed that failure to administer stress steroids generated only two claims that resulted in liability payments, and both of these cases were complicated by other issues (written personal communication, Karen L. Posner, Ph.D., Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, December 2015). It is unclear whether this paucity of claims is due to underdiagnosis of adrenal crisis or overtreatment of perioperative patients with steroids. We now review and evaluate the current data on the use of perioperative stress-dose steroids and propose approaches to administration and dosing.
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