Kohl and Schwartz reported an algorithm for the perioperative management of a patient with adrenal insufficiency. The authors are from the University of Pennsylvania.
Patient selection - one or both of the following:
(1) current therapy with >= 20 mg per day of prednisone (or equivalent) for >= 5 days
(2) clinical findings consistent with adrenal insufficiency (hyponatremia, hyperkalemia, hypotension, eosinophilia, etc)
Parameters:
(1) timing of surgery (elective, urgent, emergent)
(2) stress associated with procedure (minor, moderate, major
(3) preoperative short ACTH stimulation test (performed if urgent or elective surgery involving moderate or severe stress)
|
Timing |
Stress |
Management |
|
emergent |
minor |
25 mg hydrocortisone (or equivalent) IV |
|
emergent |
moderate |
50 mg hydrocortisone (or equivalent) IV |
|
emergent |
severe |
100 mg hydrocortisone (or equivalent) IV |
|
urgent or elective |
minor |
25 mg hydrocortisone (or equivalent) IV only if symptomatic during surgery |
|
urgent or elective |
moderate |
50 mg hydrocortisone (or equivalent) IV if short ACTH stimulation test abnormal OR symptomatic during surgery |
|
urgent or elective |
severe |
100 mg hydrocortisone (or equivalent) IV if short ACTH stimulation test abnormal OR symptomatic during surgery |
where:
• A minor procedure involves local anesthesia OR duration < 1 hour.
• A moderate procedure involves most orthopedic or vascular surgeries.
• A major surgery involves prolonged operations or major resections including cardiopulmonary bypass.
If corticosteroids are given during surgery:
(1) continue corticosteroid therapy q8h for 48 hours
(2) consult endocrinologist if therapy is needed beyond 48 hours after surgery
Specialty: Anesthesiology, Endocrinology
