Peri-operative steroid supplementation.

Abstract

We read with interest the excellent review on peri-operative steroid supplementation by Nicholson et al. [1]. We agree that supraphysiological dosing schedules are unnecessary and possibly harmful. We also agree that in modern surgical and anaesthetic practice, the benefits of the stress response are uncertain. Anaesthetic techniques that suppress the stress response may in fact improve patient outcome. It seems illogical to suppress the cortisol response to stress in some patients to good effect while mimicking it by supplementation in others (the regimen recommended by the authors and originally proposed by Kehlet was based on the principal of imitating the normal hypothalamic–pituitary–adrenal response to surgery). The primate work by Udelsman showed that only resting circulating values of cortisol were necessary to maintain homeostasis during surgical stress [2]. Any patient receiving steroids in a dose capable of suppressing the hypothalamic–pituitary–adrenal axis (> 10 mg predisolone per day) is receiving more than basal cortisol levels. Friedman et al. described 28 patients undergoing major orthopaedic surgery who had been taking an average of 10 mg prednisolone for 7 years and who received no increase in steroid dosage in the peri-operative period [3]. There was no clinical or biochemical evidence of adrenocortical insufficiency in any patient. We feel therefore that it is quite possible that continuation of the patient's usual steroid treatment is all that is required. However, in view of the fact that the current recommendation is still that patients receive supplementation, may we propose a simpler and more practical supplementation regimen than an intravenous infusion of hydrocortisone that may need to be continued for 72 h? This proposed regimen (Table 1) is based on the following premises: 1 The stress response to moderate or major surgery is equivalent to ≈100 mg hydrocortisone and to minor surgery is equivalent to ≈50 mg hydrocortisone [1]. 2 The steroid deficiency that results from hypothalamic–pituitary–adrenal axis suppression is a glucocorticoid deficiency and not a mineralocorticoid deficiency. 3 The relative glucocorticoid potency of hydrocortisone, prednislone and methylprednisolone is 1 : 4 : 5 [4]. 4 Oral prednisolone or intravenous methylprednisolone have half-lives that make them suitable for daily or twice daily dosing [5, 6]. 5 Peri-operative steroids are presently given to continue the treatment of the underlying condition and to mimic the stress response. The dose given should be equivalent to whichever of these is the greater and not a summation of the two. 6 Stimulation tests of hypothalamic–pituitary–adrenal axis function are rarely a practical option. We would be interested to know whether Nicholson et al. feel that our proposed regimen is a safe alternative to the regimen that they recommend?