Supplemental perioperative steroids for surgical patients with adrenal insufficiency
Abstract
Background
Adrenal crisis is a life threatening condition which can be induced by stress during surgery in patients with adrenal insufficiency. This may be prevented by perioperative administration of high doses of steroids. There is disagreement on whether supplemental perioperative steroids are required and, when administered, on the amount and frequency of doses. The review was originally published in 2009 and was updated in 2012.
Objectives
To assess whether it is necessary to administer supplemental perioperative steroids in adult patients on maintenance doses of glucocorticoids because of adrenal insufficiency.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2); MEDLINE (1966 to February 2012); EMBASE (1980 to February 2012); LILACS (1982 to May 2012); and the databases of ongoing trials. We handsearched the Journal of Clinical Endocrinology and Metabolism (1982 to 2008), Clinical Endocrinology (1972 to 2008), Surgery (1948 to 1994), Annals of Surgery (1948 to 1994), and Anaesthesia (1948 to 2001). The original search was performed in January 2009.
Selection criteria
We included randomized controlled trials that compared the use of supplemental perioperative steroids to placebo in adult patients on maintenance doses of steroids and who required surgery.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data. Study authors were contacted for missing information. We used mean differences and standard deviations to summarize the data for each group.
Main results
Two trials involving 37 patients were included. These studies reported that supplemental perioperative steroids were not required during surgery for patients with adrenal insufficiency. Neither study reported any adverse effects or complications in the intervention and control groups. Both studies were graded as having a high risk of bias.
Authors' conclusions
Owing to the small number of patients, the results may not be representative. Based on current available evidence, we are unable to support or refute the use of supplemental perioperative steroids for patients with adrenal insufficiency during surgery.
PICOs
Plain language summary
There is insufficient evidence on whether additional steroids are required at the time of surgery for patients with adrenal insufficiency
The adrenal glands are located above the kidneys. They are responsible for producing hormones in response to stress. Adrenal insufficiency is a hormonal disorder that occurs when the adrenal glands do not produce enough hormones. Patients with adrenal insufficiency may be more likely to develop adrenal crisis. This is a life threatening condition caused by insufficient steroid hormone in response to stress during surgery. This updated Cochrane review examined the need for additional steroids during surgery, on top of the normal physiological dose requirement. There was insufficient evidence from randomized controlled trials on whether or not to use additional steroids at the time of surgery. We ran our searches to February 2012 and identified two randomized controlled trials which examined a total of 37 patients. These patients underwent minor to moderate surgery ranging from dental surgery to total knee replacement. An unexpected fall in blood pressure may indicate the onset of adrenal crisis. Both trials reported no change in the patients’ blood pressure whether or not additional steroids were given during surgery. The results from both trials suggest that additional steroids are not required during surgery. There were also no reported side effects in either trial. The findings are limited by the small number of patients examined. Many recommendations on the use of an additional steroids regimen still exist for patients undergoing surgery and the amount recommended as required is dependent on the duration and severity of surgery. However, the benefit or harm of these recommendations has not been properly investigated.
