Stress Dose Steroids

[pie944]

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How do you guys manage the decision in patients taking steroid supplementation for diseases other than glucocorticoid deficiency? Which patients definitely need supplementation in your personal opinions? How do you dose the perioperative steroids(mg, frequency, taper all in the context of specific surgeries)?

Miller states that "Although the precise amount required has not been established, we usually intravenously administer the maximum amount of glucocorticoid that the body manufactures in response to maximal stress (i.e., approximately 200 mg/day of hydrocortisone phosphate per 70 kg body weight). For minor surgical procedures, we usually give hydrocortisone phosphate intravenously, 100 mg/day per 70 kg body weight. Unless infection or some other perioperative complication develops, we decrease this dose by approximately 25% per day until oral intake can be resumed. At this point, the usual maintenance dose of glucocorticoids can be administered."

This has no citations and seems to based off the prior paragraph statement that "Under perioperative conditions, the adrenal glands secrete 116 to 185 mg of cortisol daily. Under maximum stress, they may secrete 200 to 500 mg/day."

 

[bullard]

A lot of voodoo on this subject and very little good data. If you ask ten anesthesiologists about this you'll get ten different answers, which means it doesn't matter how or whether you give stress dose steroids or not.

 

[PMPMD]

How do you guys manage the decision in patients taking steroid supplementation for diseases other than glucocorticoid deficiency? Which patients definitely need supplementation in your personal opinions? How do you dose the perioperative steroids(mg, frequency, taper all in the context of specific surgeries)?

Miller states that "Although the precise amount required has not been established, we usually intravenously administer the maximum amount of glucocorticoid that the body manufactures in response to maximal stress (i.e., approximately 200 mg/day of hydrocortisone phosphate per 70 kg body weight). For minor surgical procedures, we usually give hydrocortisone phosphate intravenously, 100 mg/day per 70 kg body weight. Unless infection or some other perioperative complication develops, we decrease this dose by approximately 25% per day until oral intake can be resumed. At this point, the usual maintenance dose of glucocorticoids can be administered."

This has no citations and seems to based off the prior paragraph statement that "Under perioperative conditions, the adrenal glands secrete 116 to 185 mg of cortisol daily. Under maximum stress, they may secrete 200 to 500 mg/day."

This is somewhat controversial and the evidence to support either side is to my knowledge generally lacking. I think Miller's recommendations of tailoring steroid dose to the magnitude of surgery (and therefore stress) is reasonable. I definitely don't think every patient on chronic steroids needs 50q6 or 100q8.

I would supplement for big cases - major vascular, CT, big open belly whacks, etc. This is arbitrary and unscientific.

Also, even if the pt is taking the steroids for a reason other glucocorticoid deficiency, they will all be at risk for adrenal suppression with chronic administration.

We'll start pts in our SICU on steroids for just about any reason (this fact may be of use to the OP).

 

[PMPMD]

How do you guys manage the decision in patients taking steroid supplementation for diseases other than glucocorticoid deficiency? Which patients definitely need supplementation in your personal opinions? How do you dose the perioperative steroids(mg, frequency, taper all in the context of specific surgeries)?

Didn't see the rest of your question.

I've typically seen 50q6 or 100q8 to replicate the endogenous stress range of 200-300mg/day. As far as tapering, they're already on chronic steroids and presumably adrenally suppressed, so I would only taper from stress dose down to home dose. The length of this taper depends on how long and how big the stress of surgery is. If I'm seeing them, they're in the SICU, so they've had a big op, or a long lingering course, are chronically ill, or some combination thereof. So I will continue stress dose until they improve clinically, then taper over a few days down to home dose.

 

[fakin' the funk]

We'll start pts in our SICU on steroids for just about any reason (this fact may be of use to the OP).

I think the only downside to empiric, stress-dose hydrocortisone for presumed CIRCI is the fact that you've put that label on them and bought them >5-7 days of a medication. But the drug itself is low risk and has a big upside.

 

[PMPMD]

Requirement of Perioperative Stress Doses of Corticosteroids
A Systematic Review of the Literature

Paul E. Marik, MD; Joseph Varon, MD
Arch Surg.*2008;143(12):1222-1226.

Objective* To determine the requirement for perioperative supplemental (stress) doses of corticosteroids in patients receiving long-term corticosteroid therapy and undergoing a surgical procedure. Corticosteroids are among the most commonly prescribed medications and will predictably result in suppression of the hypothalamic-pituitary-adrenal axis with long-term use. Patients receiving therapeutic dosages of corticosteroids frequently require surgery; these patients are almost universally treated with stress doses of corticosteroids during the perioperative period.

Data Sources* MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and citation review of relevant primary and review articles.

Study Selection* Randomized controlled trials (RCTs) comparing stress doses of corticosteroids with placebo and cohort studies that followed up patients after surgery in which perioperative stress doses of corticosteroids were not administered.

Data Extraction* Data were abstracted on the study design, study size, study setting, patient population, dosage and duration of previous corticosteroid therapy, adrenal function testing results, surgical intervention, corticosteroid dosing regimen, intraoperative and postoperative hemodynamic profile, and incidence of adrenal crisis.

Data Synthesis* Nine studies met our inclusion criteria, including 2 RCTs and 7 cohort studies. These studies enrolled a total of 315 patients who underwent 389 surgical procedures. In the 2 RCTs, there was no difference in the hemodynamic profile between patients receiving stress doses of corticosteroids compared with patients receiving only their usual daily dose of corticosteroid. In the 5 cohort studies in which patients continued to receive their usual daily dose of corticosteroid without the addition of stress doses, no patient developed unexplained hypotension or adrenal crisis. One patient in each of the 2 cohort studies (5% and 1% of the cohort) in which the usual daily dose of corticosteroid was stopped 48 and 36 hours before surgery developed unexplained hypotension; both of these patients responded to hydrocortisone and fluid administration.

Conclusions* Patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids so long as they continue to receive their usual daily dose of corticosteroid. Adrenal function testing is not required in these patients because the test is overly sensitive and does not predict which patient will develop an adrenal crisis. Patients receiving physiologic replacement doses of corticosteroids owing to primary disease of the hypothalamic-pituitary-adrenal axis, however, require supplemental doses of corticosteroids in the perioperative period.

 

[pie944]

Requirement of Perioperative Stress Doses of Corticosteroids
A Systematic Review of the Literature

Paul E. Marik, MD; Joseph Varon, MD
Arch Surg.*2008;143(12):1222-1226.

Conclusions* Patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require stress doses of corticosteroids so long as they continue to receive their usual daily dose of corticosteroid. Adrenal function testing is not required in these patients because the test is overly sensitive and does not predict which patient will develop an adrenal crisis. Patients receiving physiologic replacement doses of corticosteroids owing to primary disease of the hypothalamic-pituitary-adrenal axis, however, require supplemental doses of corticosteroids in the perioperative period.

Found this earlier today, it seems that stress dose steroids are probably over used. The downside to dosing them seems to be minimal, but based off this it seems that the actual benefit is minimal in most cases too. Do people refrain from giving steroids during the case until you start facing refractory hypotension to fluids and pressors? Does it matter if they are given prior to the 'stress' or during? If timing doesn't matter, it's possible that for the majority of cases one could hold off on giving them until faced with this situation?

 

[Idiopathic]

i see these patients in the SICU mostly, ill give steroids to certain subsets, but I rarely stress dosed them in the OR, unless someone had a huge oral requirement at home, missed a day, was having a long/stressful surgery and I was using etomidate

 

[Precedex]

Have you ever given 4 mg of dexamethasone for antiemesis? That is stress-dose steroids.

http://www.globalrph.com/steroid.cgi

 

[PMPMD]

Have you ever given 4 mg of dexamethasone for antiemesis? That is stress-dose steroids.

http://www.globalrph.com/steroid.cgi

~100mg hydrocortisone.

Yup that'll do it.

 

[TheSweetness]

TI
Adrenal suppression and steroid supplementation in renal transplant recipients.
AU
Bromberg JS, Alfrey EJ, Barker CF, Chavin KD, Dafoe DC, Holland T, Naji A, Perloff LJ, Zellers LA, Grossman RA

SO
Transplantation. 1991;51(2):385.


The use of increased dosages of glucocorticoids during periods of physiologic stress in allograft recipients represents a clinical dilemma in that the short-term exogenous therapy required may significantly impair wound healing and immunocompetence. To investigate whether "stress steroids" are actually necessary, a prospective study was conducted in 40 renal allograft recipients admitted with significant physiologic stress. Stress categories included sepsis, metabolic abnormalities, and surgery. These patients received only their baseline prednisone immunosuppression (5-10 mg/day) and no supraphysiologic or stress doses of glucocorticoids. The clinical course of the patients revealed no evidence of adrenal insufficiency. There was no mortality, increase in hospital stay, or eosinophilia. Five episodes of hyponatremia and seven instances of hypotension were attributed to primary disease processes and responded promptly to specific treatment without steroid supplementation. Biochemical evaluation during stress revealed suppression of ACTH levels in 74.5% of episodes, elevation of urinary free cortisol levels in 79.1% of episodes, and elevation of isolated serum cortisol levels in 55.9% of episodes. This suggested that these patients had physiologically adequate adrenal function. The cosyntropin stimulation test overestimated the incidence and degree of clinically significant adrenal dysfunction (63% of patients) and was not a useful indication of a requirement for additional glucocorticoids. We conclude that functional adrenal suppression is uncommon in renal allograft recipients receiving baseline prednisone immunosuppression (5-10 mg/day) and that the demands of physiologic stress are met by a combination of endogenous adrenal function plus exogenous, baseline, immunosuppressive doses of glucocorticoids. Supra-physiologic or high doses of so-called "stress steroids" are not required. The cosyntropin stimulation test has significant clinical limitations and did not serve to alter clinical care.


AD
Department of Surgery, Hospital of University of Pennsylvania, Philadelphia 19104.

 

[TheSweetness]

" In 1952 Fraser et al published a single case report in which a patient taking exogenous corticosteroids experienced postoperative hypotension and death. This was followed by a similar report in 1953 by Lewis et al. These reports have been viewed as the initial clinical recognition of iatrogenic adrenal insufficiency due to exogenous glucocorticoid administration. However, with a perspective of nearly forty years, the reports can be criticized for a lack of invasive hemodynamic measurements, use of vasopressors, or ekgs. In fact, one cannot be sure that the patients truly succumbed to Addisonian crises since steroid levels were not measured. Subsequent studies suggested but did not prove that exogenous glucocorticoid caused adrenal suppresion and that suppressed patients required significant glucocorticoid supplementation during periods of stress. ..." Quoted from above paper Bromber et al.

 

[pie944]

" In 1952 Fraser et al published a single case report in which a patient taking exogenous corticosteroids experienced postoperative hypotension and death. This was followed by a similar report in 1953 by Lewis et al. These reports have been viewed as the initial clinical recognition of iatrogenic adrenal insufficiency due to exogenous glucocorticoid administration. However, with a perspective of nearly forty years, the reports can be criticized for a lack of invasive hemodynamic measurements, use of vasopressors, or ekgs. In fact, one cannot be sure that the patients truly succumbed to Addisonian crises since steroid levels were not measured. Subsequent studies suggested but did not prove that exogenous glucocorticoid caused adrenal suppresion and that suppressed patients required significant glucocorticoid supplementation during periods of stress. ..." Quoted from above paper Bromber et al.

It's kinda crazy how things become so prevalent based on so little. For example the fear between IOP and Succinylcholine all started becuase of an article about intraocular physiology/IOP that includes "anecdotal personal communications from surgical colleagues to provide a rationale for the investigations."

 

[edelweiss]

I never give stress dose steroids in the OR.

If they look crappy postop in the SICU with unexplained hypotension/lethargy/generalized weakness then I will consider it. But personally I have yet to see someone whose hypotension/shock truly got better because of some steroids.

I have also not run into the situation where I think "Damn, I shoulda given some 'roids."

 

[Edamat]

Have you ever given 4 mg of dexamethasone for antiemesis? That is stress-dose steroids.

http://www.globalrph.com/steroid.cgi

I always wondered about this myself.... I have been told different things by different attendings when I've asked... some acknowledge (kind of) that 4mg decadron (often given at my hospital for anti-nausea) would be stress dose steroid, some telling me to give 100mg hydrocortisone anyways... one became a bit defensive and said that my thinking was wrong because decadron only has glucocorticoid activity and no mineralocorticoid....

I thought the glucocorticoid replacement was all you cared about for hypotension during adrenal suppression.... am I wrong?

 

[deleted171991]

Most studies I have seen are based on hydrocortisone (not dexamethasone) supplementation. Same goes for the recommendations. When truly in doubt, I would skip the dexamethasone and use HC instead. But I am pretty conservative about giving stress dose steroids (like idiopathic or PMPMD), even in cases where I don't give decadron (TIVA with propofol).

It's not about the mineralocorticoid activity indeed. It's about mounting an effective sympathetic stress response, which is not possible in the absence of glucocorticoids.

 

[urge]

Have you ever given 4 mg of dexamethasone for antiemesis? That is stress-dose steroids.

http://www.globalrph.com/steroid.cgi

I have never understood why dexamethasone for nausea is so common. I wouldn't want it on my self.

 

[urge]

I have also not run into the situation where I think "Damn, I shoulda given some 'roids."

The day when your peers throw you under the bus will come. They will cling to their "expertise" and you will get screwed, regardless of the etiology.

Then you will realize steroids are given as an insurance policy against idiots.

When your peers are giving them for cataracts.... what are you to do?

 

[loveumms]

I always wondered about this myself.... I have been told different things by different attendings when I've asked... some acknowledge (kind of) that 4mg decadron (often given at my hospital for anti-nausea) would be stress dose steroid, some telling me to give 100mg hydrocortisone anyways... one became a bit defensive and said that my thinking was wrong because decadron only has glucocorticoid activity and no mineralocorticoid....

I thought the glucocorticoid replacement was all you cared about for hypotension during adrenal suppression.... am I wrong?

I don't think I got defensive and I didn't tell you your "thinking was wrong" - that is what you inferred. You asked a question about using decadron for replacement, I responded that I had not heard of people doing that and that I would assume most of the recommendations call for hydrocortisone because it has mineralcorticoid activity along with the glucocorticoid (which is more similar to the cortisol the body produces).

Yes, the glucocorticoid activity is what you care about for blood pressure support however, mineralcorticoid activity isn't completely unimportant and there was nothing we could find when we searched regarding using only decadron.

 

[chocomorsel]

Guess yall know each other? As the resident I would avoid posting on here if your superiors know who you are. Trust me, whatever you post can be used against you. Change ur username if u can.

 

[pgg]

I have never understood why dexamethasone for nausea is so common. I wouldn't want it on my self.

Why not?

 

[deleted171991]

This exchange has to be saved, even if loveumms is just having fun.

I always wondered about this myself.... I have been told different things by different attendings when I've asked... some acknowledge (kind of) that 4mg decadron (often given at my hospital for anti-nausea) would be stress dose steroid, some telling me to give 100mg hydrocortisone anyways... one became a bit defensive and said that my thinking was wrong because decadron only has glucocorticoid activity and no mineralocorticoid....

I thought the glucocorticoid replacement was all you cared about for hypotension during adrenal suppression.... am I wrong?

I don't think I got defensive and I didn't tell you your "thinking was wrong" - that is what you inferred. You asked a question about using decadron for replacement, I responded that I had not heard of people doing that and that I would assume most of the recommendations call for hydrocortisone because it has mineralcorticoid activity along with the glucocorticoid (which is more similar to the cortisol the body produces).

Yes, the glucocorticoid activity is what you care about for blood pressure support however, mineralcorticoid activity isn't completely unimportant and there was nothing we could find when we searched regarding using only decadron.

 

[loveumms]

Not having fun - found it coincidental I just had this exact conversation with one of the residents in my program the day before this post. Guess online forums are not always anonymous …. guess I also need to maybe change my teaching style ….

 

[loveumms]

Guess yall know each other? As the resident I would avoid posting on here if your superiors know who you are. Trust me, whatever you post can be used against you. Change ur username if u can.

I don't know many attendings who would use an online forum against anyone. It is true though that when you post something online, especially when you give specifics, people can probably figure out who you are if they know you.

Furthermore, I always urge people to be very careful what you post on social media. This seems like common sense but I see plenty of young people positing totally inappropriate things (which never actually get erased once posted). Many employers now look at Facebook, twitter and instagram before hiring candidates. Posting pictures of you out drinking or doing other 'less then desirable' things can mean not getting a job.

 

[chocomorsel]

Loveumms, trust me they are out there. They were stalking me on this forum when I was a resident. Sad but true. Whatever they could find to use against me, they tried. Thank God that's now over and I am moving on with my life.

 

[loveumms]

Loveumms, trust me they are out there. They were stalking me on this forum when I was a resident. Sad but true. Whatever they could find to use against me, they tried. Thank God that's now over and I am moving on with my life.

That's really sad and I'm sorry that happened to you.

 

[chocomorsel]

Thanks, Loveumms. At least I am able to move on. My union helped me out and I graduated on time, and am working without difficulty. Amazing what a change in environment does for one.

 

[BLADEMDA]

Table 2: Recommendations for Stress Dose of Steroids in Anesthesiology Textbooks (references 9-12)

Source Text

Recommendations

Clinical Anesthesiology (8)

Hydrocortisone 100mg every 8 h the evening before or on morning of surgery. For diabetics, give 25 mg hydrocortisone at induction followed by a 100 mg infusion for 24 hours.

Clinical Anesthesia (9)

Hydrocortisone 200-300 mg/70 kg body weight in divided doses on the day of surgery (higher doses for patients undergoing more extensive surgical procedures)

Principles and Practice of Anesthesiology (10)

Usual maintenance dose of steroid perioperatively with symptomatic management as needed.

OR

Stress dose of steroids based on the degree of perioperative stress. Minor surgical stress (e.g. inguinal herniorrhaphy), a single dose of hydrocortisone 25 mg the day of surgery. Moderate stress (e.g. open cholecystectomy, lower extremity vascular procedure, total joint replacement, segmental colectomy, hysterectomy), hydrocortisone 50-75 mg for 1-2 days, and resume usual dose thereafter. Major surgical stress (e.g. Whipple procedure, esophagogastrectomy, total colectomy, cardiopulmonary bypass), hydrocortisone 100-150 mg for 2-3 days, and resume usual dose thereafter.

Anesthesia and Co-Existing Disease (11)

Similar dosing recommendations from Principles and Practice of Anesthesiology but divergent in recommending a tapered steroid dose over a 1-2 days period instead of resuming the usual dose. Also, no steroid supplementation necessary for superficial surgical and dental procedures/biopsies.

Miller’s Anesthesia (12)

Minor surgical procedures, hydrocortisone 100 mg/day/70 kg body weight followed by tapering in 25% increments until baseline steroid dose. Maximum stresses, hydrocortisone 200 mg/day/70 kg body weight followed by tapering in 25% increments until baseline steroid dose.


Table 3: Recommendations for corticosteroid coverage for surgery in patients taking exogenous corticosteroids are as follows (Modified from UpToDate, reference 6)

Minor surgical procedures: Morning steroid dose, but no supplementation necessary.

Moderate surgical procedures (e.g., lower extremity revascularization, total joint replacement): Morning steroid dose, plus supplementation with hydrocortisone 50 mg I.V., intraoperatively, and 25 mg every 8 hours for 24 hours. Resume routine dose thereafter.

Major surgical procedures (e.g., cardiothoracic surgery, major abdominal surgery): Morning steroid dose, plus supplementation with hydrocortisone 100 mg I.V., intraoperatively, and 50 mg every 8 hours for 24 hours. Taper dose by half per day to maintenance level.

 

[BLADEMDA]

I use table 3 for patients taking more than 5 mg of prednisone per day. 5 mg or less and I rarely give stress steroids.

Also, I tell the surgeons to resume usual PO steroids as soon as possible and stop the IV hydrocortisone.

 

[BLADEMDA]

Most of my partners just give a single, one time dose of hydrocortisone IV for patients undergoing minor or moderate surgery who require stress dose steroids


http://www.eric.vcu.edu/home/resources/consults/PreOp_Steroids.pdf