Perioperative Hypocortisolism – An Ongoing Conundrum (Preprint)

UNSTRUCTURED Adrenal crisis can be triggered by surgery leading to dire consequences. Based on early evidence in the 1950s, the medical fraternity has been pre-emptively providing supplemental dose of steroids for patients with known adrenal insufficiency and to those at risk. However, this approach has been refuted by subsequent studies. This led to a quandary as whilst adrenal crisis is to be avoided, patients should not be exposed to superfluous administration of steroids which can cause detrimental effects. Numerous studies have ineffectually attempted to identify the patients at risk by means of quantifying the amount of preoperative steroids consumed and by utilising basal and dynamic testing. Studies indicate that given the significant variability between individuals on the requirements of perioperative supplemental steroids, a standard encompassing guideline should not be implemented. Instead a personalized approach should be taken for each case. Steroids at preoperative doses will be adequate in the perioperative period for most cases. However, all patients must be closely monitored for any possible features of hypocortisolism and the threshold for supplemental steroid administration should be low. For patients given supplemental steroids, the dose should be titrated down to preoperative doses at the soonest based on the patient’s clinical progression. A short duration of high dose supplemental steroids is unlikely to result in any adverse effects.