Stress dose steroids, thoughts?

[sigrhoillusion]

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What's everyone's thoughts on these, cause the evidence always seems lacking or changes every few years.

Obviously you have the classic training of being on X amount of steroids for X amount of time, and then factor in surgical stress between mild, mod and high stress procedures.

Only reason I ask is that have a patient tomorrow with panhypopit (not sure how severe) but per the "endo clearance note" they just say "stable for surgery" and recommend "stress dose steroids for one day prior, DOS and then POD#1" but don't really go into detail of how severe his symptoms are or what exactly this stress dose regiment should be.

Looked through his meds and it looks like he's on only 5mg of oral hydrocortisone a day, which seems pretty low (about 1-1.5mg prednisone equivalent) which seems not even worthy of coverage outside of his typical daily dose. But then you got this endocrinologist saying to stress dose him...?

Here's arecent review article on stress dose steroids.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747280/

What's everyone do around here?

 

[vector2]

The reason this case doesn't make sense is because the patient's current treatment doesn't make any sense. The recommended physiologic replacement for panhypopit is 15-30 mg of hydrocortisone a day over divided doses. Regardless of how much his current dose is, if he has true PHP (minimal response to low-dose ACTH stim) then I would definitely give steroids. I suspect the literature about stress dose steroids is wishywashy because a lot of people on chronic steroids don't have a large degree of HPA suppression and produce a fair amount of cortisol in response to surgery. If one does not even have a functioning HPA, then you certainly can't expect a stress production of 5-10x physiologic levels.

If I have a patient who has taken pred 5/day for more than a week in the last 6 months and is having major surgery, I'll give hydrocort 50q8h on day 1, 25q8 on day 2 and then put them on their home dose if they're doing fine.

 

[deleted171991]

What's everyone's thoughts on these, cause the evidence always seems lacking or changes every few years.

Obviously you have the classic training of being on X amount of steroids for X amount of time, and then factor in surgical stress between mild, mod and high stress procedures.

Only reason I ask is that have a patient tomorrow with panhypopit (not sure how severe) but per the "endo clearance note" they just say "stable for surgery" and recommend "stress dose steroids for one day prior, DOS and then POD#1" but don't really go into detail of how severe his symptoms are or what exactly this stress dose regiment should be.

Looked through his meds and it looks like he's on only 5mg of oral hydrocortisone a day, which seems pretty low (about 1-1.5mg prednisone equivalent) which seems not even worthy of coverage outside of his typical daily dose. But then you got this endocrinologist saying to stress dose him...?

Here's arecent review article on stress dose steroids.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3747280/

What's everyone do around here?

Nothing to lose by giving him a dose based on surgical stress. People used to die from this, so it's just not worth the risk.

One more thing to consider: regardless of his dose at rest, the surgical stress can uncover the his ACTH/adrenal insufficiency. That's why it's called a stress dose.

 

[Planktonmd]

What is the surgery?

 

[Robotic Wis-Hipple]

Any time in the last 6mo? There are a lot of copd'ers getting short courses of steroids, I'd assume you're stress dosing people a lot.

 

[pgg]

Most of these patients, an anti-emetic / pain adjunct dose of dexamethasone will cover it.

 

[Planktonmd]

Most of these patients, an anti-emetic / pain adjunct dose of dexamethasone will cover it.

Unfortunately that might not be totally accurate since Dexamehasone has negligible mineralocorticoid activity.
But whenever you are not sure what to do just give Hydrocortisone 50-100 mg. It doesn't hurt.

 

[pgg]

Unfortunately that might not be totally accurate since Dexamehasone has negligible mineralocorticoid activity.
But whenever you are not sure what to do just give Hydrocortisone 50-100 mg. It doesn't hurt.

Perioperative hypotension from secondary adrenal insufficiency is not related to mineralocorticoid activity. It's all glucocorticoid. Dexamethasone is fine. Some would argue it's preferable since it's actually targeting the relevant mechanism of hypotension, and mineralocorticoids can cause fluid retention, edema, hypokalemia (though that's less likely these days now that really huge "stress doses" aren't commonly given).

I'm not saying there's something wrong with 100 mg of hydrocortisone, except that it's not always in the drawer but dexamethasone is. 🙂

 

[GravelRider]

Most of these patients, an anti-emetic / pain adjunct dose of dexamethasone will cover it.

This is what I do. Unless there is a clear reason to give hydrocortisone, the dexamethasone works for PONV prophylaxis and as a stress dose if needed.

 

[Planktonmd]

Perioperative hypotension from secondary adrenal insufficiency is not related to mineralocorticoid activity. It's all glucocorticoid. Dexamethasone is fine. Some would argue it's preferable since it's actually targeting the relevant mechanism of hypotension, and mineralocorticoids can cause fluid retention, edema, hypokalemia (though that's less likely these days now that really huge "stress doses" aren't commonly given).

I'm not saying there's something wrong with 100 mg of hydrocortisone, except that it's not always in the drawer but dexamethasone is. 🙂

I agree with you on the pathophysiology of the adrenal crisis in secondary adrenal insufficiency, but if you want to replace the cortisol response with something similar then Hydrocortisone makes more sense, and that extra mineralocorticoid activity is probably helpful to maintain the hemodynamics.
Remember these patients are usually on Hydrocortisone that does have about 80% of cortisol's mineralocorticoid potency, so you might want to continue that the day of surgery.

 

[sigrhoillusion]

So just an update. Patient was actually on 10mg BID. Endo had told mom to give him 25mg day before, 25mg in AM, 25mg POD 0 and then 25mg POD1 in AM and go back to regular schedule.

It was a short hand contacture procedure. Was thinking of blocking arm, but patient wasn't the best candidate due to cooperation issues. Just did LMA and local from surgeon. BP dipped a little on induction, but then cruised the rest of the way, LMA out deep, chilling in PACU... on to the next cup of coffee.

 

[dhb]

Who would have thought 😎

 

[deleted171991]

So just an update. Patient was actually on 10mg BID. Endo had told mom to give him 25mg day before, 25mg in AM, 25mg POD 0 and then 25mg POD1 in AM and go back to regular schedule.

It was a short hand contacture procedure. Was thinking of blocking arm, but patient wasn't the best candidate due to cooperation issues. Just did LMA and local from surgeon. BP dipped a little on induction, but then cruised the rest of the way, LMA out deep, chilling in PACU... on to the next cup of coffee.

You should have started with this. 🙂

 

[Planktonmd]

You should have started with this. 🙂

😉

 

[sigrhoillusion]

You should have started with this. 🙂

Well I didn't know how long it was going to take. usually they are scheduled as depuytren contracture repair but it was listed on schedule as something that sounded different. also didn't know about patient's mental status until today.

 

[DrBeaker]

Home dose including AM of surgery. Then think if the surgery is low, intermediate, or high stress. Low likely doesn't need a stress. Intermediate 50, high 100.

Dexamethasone is pure glucocorticoid, therefore not a true stress dose. And it's overkill. 4 mg is about 104 mg hydrocortisone.

 

[deleted171991]

Dexamethasone is pure glucocorticoid, therefore not a true stress dose.

So you think his mineralocorticoid production is significantly decreased because of the lack of ACTH?

And it's overkill. 4 mg is about 104 mg hydrocortisone.

- It's 100.
- No, it's 99!
- You're wrong, it's 101!
- Come on, it's 103, everybody knows that.

😛 😛 😛