Corticosteroids are prescribed commonly to patients with autoimmune or pulmonary diseases, post‐transplant and neurosurgery, as well as to patients with adrenal insufficiency [1, 2]. These patients are at risk of tertiary adrenal gland insufficiency, for which supplementation of corticosteroids during stress, such as surgery, is advised [3, 4]. The Peri‐operative Replacement of Exogenous Steroids (PREdS) study performed an audit of compliance to guidelines for supplemental corticosteroids in patients with possible adrenal insufficiency in the UK [5]. A total of 21,411 adult patients undergoing surgery under the care of an anaesthetist were screened, of whom 277 (1.3%) used corticosteroids (i.e. they were considered at risk of tertiary adrenal gland insufficiency). Peri‐operative prescription of supplementation was fully compliant in only 9% of the patients and 14% received none.
In a retrospective cohort study, we investigated guideline adherence for such patients in our academic centre. The local clinical guideline is based on a Dutch nationwide guideline, comparable with the one used in the UK (Table 1). Patients are deemed at risk if they are using prednisolone ≥ 7.5 mg or equivalent. Supplementation dosage depends on surgical risk, so we documented compliance based on a patient's surgical procedure risk.
Table 1.
Corticosteroid supplementation guidelines.
| Type of surgery* | Pre‐operative | Postoperative | ||
|---|---|---|---|---|
| Day of surgery | Day 1 | Day 2 | Day 3 | |
| Low‐risk | 100 mg hydrocortisone i.v. or i.m. 1 h before surgery | n/a | n/a | n/a |
| Intermediate/high‐risk | 100 mg hydrocortisone i.v. or i.m. 1 h before surgery | 3 × 40 mg hydrocortisone orally or 3 × 50 mg hydrocortisone i.v. or i.m. | 1 × 40 mg and 2 × 20 mg hydrocortisone orally | 3 × 20 mg hydrocortisone orally |
| 100 mg hydrocortisone i.v. during induction | Taper to pre‐operative dose | |||
| 2 × 50 mg hydrocortisone i.v. or i.m with a 6‐h interval | ||||
i.v., intravenous; i.m., intramuscular; n/a, not applicable.
The dosages of this local translation of the national guidelines, are the same for all patients with continuation of the pre‐operative corticosteroids. The local guideline was implemented in August 2013, and the latest update was February 2019.
A total of 15,246 patients undergoing elective non‐cardiac surgery under general or spinal anaesthesia between January 2017 and June 2018 were included, of whom 390 were at risk of tertiary adrenal gland‐insufficiency. Patients had a median (IQR [range]) age of 56 (45–69 [18–85]) y, 178 (45%) were female and 107 (27%) were scheduled for neurosurgery. On the day of surgery, 32 of 390 patients (8%) received hydrocortisone supplementation in accordance with the guidelines and 188 (48%) received another corticosteroid for an alternative reason, for example, dexamethasone for postoperative nausea or for neurosurgery. None of the remaining 170 (44%) patients received supplementation.
Of the 147 patients (38%) undergoing low‐risk surgery, 26 (18%) received supplementation according to the guidelines, while 38 (36%) received corticosteroids for other reasons, of whom 36 (95%) received an adequate equivalent dose. Of the 243 patients (62%) undergoing intermediate/high‐risk surgery, 6 (2%) received supplemental corticosteroids according to the guidelines and 150 (62%) received corticosteroids for other reasons. Of these 150 patients, 27 (18%) received an adequate equivalent dose. On the first postoperative day, peri‐operative prescription of supplementation was fully compliant in 10 (4%) of the 243 intermediate/high‐risk patients.
In conclusion, our hospital recorded an 8% compliance rate with the guidelines for prescribing peri‐operative corticosteroid supplementation, similar to the 9% compliance rate found in the PREDs study [5]. Our study predates the Association of Anaesthetists' guidelines, yet the results indicate that peri‐operative corticosteroid supplementation for chronic users remains controversial [4]. Despite over 60 years of recommendations, these guidelines are based on sparse, low‐quality evidence and need further scrutiny.
Acknowledgements
No competing interests declared.
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