Shaw brings the topic to another level when he states that, given the evidence we have today, it is still prudent to consider perioperative steroid coverage.22 The benefit—avoiding life-threatening adrenal insufficiency—outweighs the risk of enhanced catabolism and immunosuppression, especially if the steroid coverage is physiologic and of a very short duration.
Perioperative Glucocorticoid Coverage
Current recommendations for steroid coverage take into account the normal physiologic response to routine surgery. The idea is to mimic the transient increase in cortisol levels during the surgical and postoperative period but not to exceed the levels or the duration of the physiologic response. Doses above the physiologic ranges offer no particular benefit in routine surgical stress.5
Most of the current recommendations stem from those proposed by Salem and colleagues in 1994.5
For almost 50 years after it was first recognized, the need for steroid replacement in surgical situations had been addressed with high doses that created new problems in the forms of poor tissue healing and immunosuppression, causing a major dilemma in the surgical world. Now, with a more conservative and physiologic approach, the adverse consequences of glucocorticoid supplementation can be minimized and perhaps even prevented. TH
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- Hench PS, Slocumb CH, Polley HF, et al. Effect of cortisone and pituitary adrenocorticotropic hormone (ACTH) on rheumatic diseases. JAMA. 1950 Dec 16;144(16):1327-1335.
- Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. JAMA. 1952;149:1542-1543.
- Lewis L, Robinson RF, Yee J, et al. Fatal adrenal cortical insufficiency precipitated by surgery during prolonged continuous cortisone treatment. Ann Intern Med. 1953; 39:116-126.
- Salem M, Tainsh RE Jr, Bromberg J, et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg. 1994 Apr;219(4):416-425.
- Jabbour SA. Steroids and the surgical patient. Med Clin North Am. 2001 Sep;85(5):1311-1317.
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- Chernow B, Alexander HR, Smallridge RC, et al. Hormonal responses to graded surgical stress. Arch Intern Med. 1987 Jul;147(4):1273-1278.
- Raff H, Norton AJ, Flemma RJ, et al. Inhibition of the adrenocorticotropin response to surgery in humans: interaction between dexamethasone and fentanyl. J Clin Endocrinol Metab. 1987 Aug;65(2):295-298.
- Udelsman R, Norton JA, Jelenich SE, et al. Responses of the hypothalamic-pituitary-adrenal and renin-angiotensin axes and the sympathetic system during controlled surgical and anesthetic stress. J Clin Endocrinol Metab. 1987 May;64(5):986-994.
- Kehlet H. A rational approach to dosage and preparation of parenteral glucocorticoid substitution therapy during surgical procedures. A short review. Acta Anaesthesiol Scand. 1975;19(4):260-264.
- Kehlet H. Clinical course and hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated surgical patients. Copenhagen: FADL
- Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003;32:367-383.
- Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders. Anesthesiol Clin North America. 2004 Mar;22(1):93-123.
- Annane D, Sebille V, Troche G, et al. A 3-level prognostic classification in septic shock based on cortisol levels and cortisol response to corticotropin. JAMA. 2000 Feb 23;283(8):1038-1045.
- Hollenberg SM, Ahrens TS, Annane D, et al. Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update. Crit Care Med. 2004 Sep;32(9):1928-1948.
- Gonzalez H, Nardi O, Annane D. Relative adrenal failure in the ICU: an identifiable problem requiring treatment. Crit Care Clin. 2006 Jan;22(1):105-118.
- Streeten DHP. Shortcomings in the low-dose (1 microg) ACTH test for the diagnosis of ACTH deficiency states. J Clin Endocrinol Metab. 1999 Mar;84(3):835-837.
- Bromberg JS, Alfrey EJ, Barker CF, et al. Adrenal suppression and steroid supplementation in renal transplant recipients. Transplantation. 1991 Feb;51(2):385-390.
- Friedman RJ, Schiff CF, Bromberg JS. Use of supplemental steroids in patients having orthopaedic operations. J Bone Joint Surg Am. 1995 Dec;77(12):1801-1806.
- Levy A. Perioperative steroid cover. Lancet. 1996 Mar;347(9005):846-847.
- Shaw M. When is perioperative ‘steroid coverage’ necessary? Available at: www.clevelandclinicmeded.com/ccjm/january2002/shaw.htm. Last accessed February 9, 2007.