Peri-operative corticosteroid supplementation guideline adherence

Abstract

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.