1. 44 y/o female, Known case of Addison's disease, For elective cholecystectomy. How to optimize the patient’s state during the surgery?

2. Management of adrenal insufficiency during surgery
Abdulelah Nuqali
Medical Intern
UQU

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

4. Normal cortisol production

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

7. 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.

8. 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.

9. Adrenal insufficiency
Primary
Addison Disease
Tuberculosis
Secondary
Iatrogenic

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

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

12. 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

13. 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.

14. 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.

15. 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