Perioperative management of patients treated with glucocorticoids

Hypothatamic-pituitary-adrenal (HPA) suppression is a common consequence of glucocorticoid therapy. Overt secondary adrenal insufficiency from this treatment is a rare but life-threatening condition. This article addresses the following issues in patients previously treated with glucocorticoids: the pathogenesis of hypotension, the incidence of perioperative adrenal insufficiency, the time course of development of HPA suppression, the time course of recovery from HPA suppression, management of HPA suppression, preoperative assessment, and perioperative management. The short adrenocorticotropic hormone test is the preferred study for preoperative assessment of adrenocortical function. Recommendations for perioperative glucocorticoid coverage of patients with HPA suppression, with lower doses than in the past, now reflect the normal physiologic response to surgical stress and consider the duration and severity of the surgical procedure.