If in any doubt, it is best to consult with the patient's endocrinologist when planning for the surgical procedure, or where this is not possible, to err on the side of caution and ensure the patient receives additional glucocorticoid cover sufficient to ensure the procedure is risk-free. An overly generous dose will do no harm, whereas under-medicated surgical procedures are a recognised cause of adrenal crisis.
The ADSHG surgical guidelines apply to all individuals who are steroid-dependent; they are relevant to people with hypopituitarism and steroid-dependence from other causes, as well as Addison's (primary adrenal insufficiency).
For steroid-dependent patients having elective surgery in hospital, it is sensible for both the surgeon and anaesthetist to read the ADSHG surgical guidelines well in advance of the surgery date and for the anaesthetist to meet with the patient as part of the pre-operative assessment and planning, to agree the peri-operative regime for glucocorticoid and/or IV fluids.
All steroid-dependent patients should be given the same “first on the list” priority for scheduled surgery as patients with insulin-dependent diabetes. Dehydration during nil by mouth is acutely destabilising for any patient whose fluid homeostasis is medication dependent, ie fludrocortisone or vasopressin dependency.
The ADSHG surgical guidelines are available for free download. They explain what level of extra medication and monitoring a steroid-dependent patient will need in the event of most types of surgery or dental work. These guidelines:
c. Bring together the most up-to-date endocrine knowledge on cortisol replacement in the steroid-dependent patien
d. Reflect a prudent level of steroid cover that can safely be administered by non-endocrinologists.
Since they were first launched in 2005, the ADSHG surgical guidelines have been endorsed in several clinical/endocrine publications. You can read these endorsements in the links below.
- Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency. Husebye, E et al, JIM, first published online Dec 2013
- EXTENSIVE EXPERTISE IN ENDOCRINOLOGY: Adrenal crisis, Allolio B, EJE 2015
- Adrenal Crisis: Still a Deadly Event in the 21st Century, Puar T et al, AJM 2016
The ADSHG surgical guidelines have also been endorsed by:
- UK Society for Endocrinology
- NICE Clinical Knowledge Summaries: Addison's disease, last revised March 2016
Published case reports identify that for individual cases, the levels of parenteral glucocorticoid specified in the ADSHG surgical guidelines may prove insufficient (1). Anaesthetists are advised to be vigilant in monitoring the patient's condition, especially where the individual has a bodyweight >90kg (2). For patients taking CYP-3A4 accelerants, eg phenytoin, it is advisable to place the patient on infusion cover to prevent rapid decompensation (3).
A 2013 UK survey of steroid-dependent patients found that surgical procedures and post-surgical recovery with inadequate steroid cover were a trigger factor for adrenal crisis reported by 19% of patients.You can read here about the findings of the 2013 survey, conducted by the ADSHG.
(1) A strategy for management of intraoperative Addisonian crisis, D'Silva et al, Interact CardioVasc Thorac Surg (2012) 14 (4): 481-482
(2) Plasma, salivary and urinary cortisol levels following physiological and stress doses of hydrocortisone, Jung C et al, BMC Endocrine Disorders 2014,14:91
(3) Adrenal crisis: still a deadly event in the 21st century, Puar T et al, Am J Med. 2016, 129:3