Correspondence  |   March 2018
In Reply
Author Notes
  • Texas Heart Institute, Baylor St. Luke’s Medical Center, Houston, Texas (M.M.L.).
  • (Accepted for publication November 27, 2017.)
    (Accepted for publication November 27, 2017.)×
Article Information
Correspondence   |   March 2018
In Reply
Anesthesiology 3 2018, Vol.128, 681. doi:
Anesthesiology 3 2018, Vol.128, 681. doi:
We thank Dr. Wax for his response to our recent article on perioperative steroid management.1  Since the publication of our article, we have received several queries regarding the use of dexamethasone as a perioperative stress-dose steroid and appreciate the opportunity to further address this topic. As Dr. Wax aptly notes, dexamethasone has significantly more glucocorticoid potency than hydrocortisone, has no mineralocorticoid effect, and can be clinically effective in the prevention of postoperative nausea and vomiting. Indeed, the recommended antiemetic dose of dexamethasone (4 mg) has at least the same glucocorticoid equivalence as the recommended intraoperative stress dose of hydrocortisone (100 mg) for patients at risk for adrenal insufficiency undergoing major surgery.1  The available literature on perioperative steroid supplementation provides dosing guidelines based on hydrocortisone, which has a shorter, more predictable half life compared to dexamethasone and is thus more easily tapered to the usual daily dose in patients requiring continued postoperative supplementation based on surgical stress. However, the literature on patients with secondary adrenal insufficiency does not make any specific recommendation as to what is the “best” stress-dose steroid to administer. Dexamethasone is not appropriate for patients with primary adrenal insufficiency or critically ill patients, both of whom require mineralocorticoid supplementation.2,3  While we agree that the use of dexamethasone may be a reasonable approach for many patients with secondary adrenal insufficiency, with additional benefit in the prevention of postoperative nausea and vomiting, we caution against a “one-size-fits-all algorithm,” especially in critically ill patients.
Competing Interests
The authors declare no competing interests.
Melanie M. Liu, M.D., Andrea B. Reidy, M.D., Siavosh Saatee, M.D., Charles D. Collard, M.D. Texas Heart Institute, Baylor St. Luke’s Medical Center, Houston, Texas (M.M.L.).
Liu, MM, Reidy, AB, Saatee, S, Collard, CD . Perioperative steroid management: Approaches based on current evidence. Anesthesiology 2017; 127:166–72 [Article] [PubMed]
Bornstein, SR, Allolio, B, Arlt, W, Barthel, A, Don-Wauchope, A, Hammer, GD, Husebye, ES, Merke, DP, Murad, MH, Stratakis, CA, Torpy, DJ . Diagnosis and treatment of primary adrenal insufficiency: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2016; 101:364–89 [Article] [PubMed]
Cooper, MS, Stewart, PM . Corticosteroid insufficiency in acutely ill patients. N Engl J Med 2003; 348:727–34 [Article] [PubMed]