Case 1: A 73-year-old woman underwent two separate major abdominal surgeries, one month apart, for the management of ovarian endometrioid adenocarcinoma. She had hypotensive crises about 30 minutes into each of the procedures, requiring metaraminol and noradrenaline infusions. Cortisol levels post-surgeries were 99 nmol/l and 23 nmol/l, respectively. Further questioning revealed exogenous steroid use, including high dose inhaled steroids (Fostair-800mcg/daily) and IM steroid injections, the last one within 12 months of surgery. Once adrenal insufficiency diagnosed, she was managed with parenteral, then oral, hydrocortisone, in the usual way. She will have further testing when appropriate she is currently undergoing chemotherapy.
Case 2: A 53-year-old woman became hypotensive during a bilateral hip replacement. She was given dexamethasone intraoperatively, then became hypotensive again and was admitted to ICU, requiring support with metaraminol for three days. Early morning cortisol was measured at 38 nmol/l, 48 hours after surgery, and 83 nmol/l, seven days later. Further questioning revealed exogenous steroid use, including multiple steroid injections to the hip (methyl prednisolone 40-120 mg) and oral prednisolone, within a year of surgery. Once adrenal insufficiency diagnosed, she was managed with parenteral, then oral hydrocortisone, in the usual way. Two months later, she underwent Synacthen testing: 0min cortisol 354 nmol/l; 30min 401 nmol/l; basal ACTH 47ng/l. She is no longer taking oral hydrocortisone.
Conclusion: Patients with hypothalamo-pituitary adrenal suppression due to exogenous steroids, across all routes, are at risk of adrenal crisis during surgery as they are unable to mount a cortisol response in response to physiological stress. IM steroids seem to be a particular issue as they result in prolonged HPA axis suppression. Risk of HPA axis suppression can be considered depending on dose of steroids given. Patients should be covered with hydrocortisone, as per standard surgical perioperative guidance. Further confirmatory testing can be done at an appropriate time, after surgery.
08 Nov 2021 - 10 Nov 2021