44 y/o female, Known case of Addison's disease, For elective cholecystectomy. How to optimize the patient’s state during the surgery?

Management of adrenal insufficiency during surgery Abdulelah Nuqali Medical Intern UQU

Outlines: Normal cortisol production Cortisol response to stress Glucocorticoid supplementation therapy during surgery

Normal cortisol production

Normal cortisol production Daily endogenous cortisol production is : 10 mg/day

Cortisol response to stress Cortisol is required for : The metabolism of carbohydrates, lipids and proteins The maintenance of vascular tone and endothelial integrity Potentiates the vasoconstrictor actions of catecholamine's and, Anti-inflammatory effects on the immune system.

Cortisol response to stress Surgery is one of the most potent activators of the HPA axis. cortisol production rate increases to 75– 150 mg/day after major surgery.

Adrenal insufficiency Primary Addison Disease Tuberculosis Secondary Iatrogenic

Glucocorticoid supplementation therapy during surgery The appropriate dose and timing of Glucocorticoids for patients undergoing surgery is controversial

No Steroids Excessive Steroids Adrenal Crisis Hyperglycemia Hypertension Impaired wound healing Increased risk of infection Excessive Steroids

Glucocorticoid supplementation therapy during surgery Current recommendation: For minor procedures such as herniorrhaphy, a dose equivalent to hydrocortisone 25 mg is suggested for the day of operation only, with a return to the usual replacement dose on the second day

Glucocorticoid supplementation therapy during surgery Current recommendation: For moderate surgical stress (e.g., cholecystectomy), divided intravenous doses equivalent to hydrocortisone 50 to 75 mg are suggested on the day of surgery and the first post-operative day, with a return to the usual dose on the second post-operative day.

Glucocorticoid supplementation therapy during surgery Current recommendation: For major surgical procedures (e.g., whipple's procedure) The authors suggest a total daily dose equivalent to 100 to 150 mg hydrocortisone given in divided doses for two to three days, then returning to the usual dose.

References: The surgical patient taking glucocorticoids, UpToDate Treatment of adrenal insufficiency in adults, UpToDate Caroline Jung and Warrick J Inder, Management of adrenal insufficiency during the stress of medical illness and surgery, Medical Journal of Australia, 2008