Corticosteroid
Relative glucocorticoid activity
Relative mineralocorticoid activity
Equivalent glucocorticoid dose (mg)
Plasma half-life (min)
Hydrocortisone
1.0
1.0
20
90
Cortisone
0.8
0.8
25
30
Prednisone
4
0.8
5
60
Prednisolone
4
0.8
5
200
Triamcinolone
5
0
4
300
Methylprednisolone
5
0
4
180
Betamethasone
25
0
0.8
100–300
Dexamethasone
25
0
0.8
100–300
Fludrocortisone
10
125
2
200
Common perioperative dosing of corticosteroids:
Airway edema – Proven role in the management of croup. For patient with prolonged intubation in the ICU, dexamethasone 5 mg IV every 6 h for a total of four doses on the day preceding extubation has been shown to reduce post-extubation stridor. Available data regarding one-time dexamethasone dose in the OR has been equivocal.
Anaphylaxis – While glucocorticoids are not helpful acutely, they may potentially help prevent recurrences and shorten the duration of the attack. Hydrocortisone 100 mg IV bolus can be given after airway, ventilation, and hemodynamic stability have been addressed.
Anti–emesis – Dexamethasone 4 mg IV can be given at induction of anesthesia for postoperative nausea and vomiting prophylaxis.
Cerebral edema from primary or metastatic tumor – During craniotomy for tumor resection, an intravenous loading dose of dexamethasone 10 mg followed by 4 mg every 6 h can be considered. For inoperable palliative maintenance therapy, oral doses of dexamethasone 4 mg twice or three times per day may be effective.
Controversy remains over whether supplemental perioperative steroids are required for patients on maintenance corticosteroids who undergo surgery. A 2009 Cochrane review concluded that there is inadequate evidence to support or refute the use of perioperative stress dose steroids [13]. In clinical practice, many clinicians routinely administer perioperative stress dose steroids to patients on maintenance corticosteroids. Obviously, careful consideration of patient comorbidities as well as the risk and benefits of steroid supplementation needs to be assessed on a case by case basis. A review of expert opinions in literature has the following recommendation [14]:
Minimal stress procedures (<1 h under local anesthesia) – Continue the usual replacement corticosteroid.
For minor stress procedures (colonoscopy, inguinal hernia repair) – Continue the usual replacement corticosteroids and administer hydrocortisone 25 mg IV at the start of the procedure.
For moderate stress procedures (open cholecystectomy, joint replacement, lower-limb revascularization, abdominal hysterectomy) – Administer IV hydrocortisone 75 mg/day on the day of the procedure (25 mg IV every 8 h), and then taper over the next 1–2 days to usual replacement doses.
For severe stress procedures (cardiothoracic, Whipple, liver resection) – Administer IV hydrocortisone 150 mg/day (50 mg IV every 8 h), then taper over the next 2–3 days to the usual replacement dose.Related posts:
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