Three tables: How to adjust the administration during the perioperative period for patients who encounter long-term oral hormones?

Author: Blue Whale Xiaohu This article is published by Yimaitong authorized by the author, please do not reprint without permission.

 Introduction: How to adjust the administration during the perioperative period for patients who encounter long-term oral hormones? We have summarized 3 tables.

Cortisol is the main glucocorticoid, produced by the fascicular zone of the adrenal cortex, controlled by the adrenocorticotropic hormone (ACTH) released from the anterior pituitary, and ACTH is controlled by the adrenocorticotropic hormone (CRH) released from the hypothalamus.

Under physiological conditions, the human body produces and releases 30 mg of cortisol every day.

Primary adrenal insufficiency is related to the diseases of the adrenal glands, including Addison's disease (autoimmune adrenal insufficiency) and congenital adrenal hyperplasia.
It is manifested by increased ACTH and decreased renin-aldosterone levels.

Patients with secondary adrenal insufficiency caused by pituitary and hypothalamic diseases and exogenous hormone therapy decrease ACTH, but continue to secrete aldosterone under the action of renin.

Long-term hormone therapy and potential adrenal crisis risk Long-term use of various routes of administration (oral, inhalation, topical, intranasal and intra-articular) hormone therapy can cause hypothalamic-pituitary-adrenal axis depression (third-grade adrenal insufficiency) , This group is at risk of potential adrenal crisis.

For example, taking the hormone ≥5mg prednisolone equivalent daily for more than 1 month can cause adrenal function suppression in some patients.

 How to adjust hormone administration during perioperative period? Insufficient production of cortisol during the stress response of surgery leads to progressive loss of vasomotor tension and decreased sensitivity of α-adrenergic receptors.

Continuous reduction of vascular tone can lead to orthostatic hypotension, which progresses to supine hypotension or even shock, which can be fatal if not corrected in time.

Postoperative antidiuretic hormone activation often induces fluid retention, and hyponatremia is prone to occur when combined with insufficient aldosterone production.

 Considering the risk of inadequate glucocorticoid response, it is supported to give individualized loading doses of glucocorticoids on the basis of continuous treatment of patients during the perioperative period (or under other stress conditions).

Therapeutic glucocorticoids include hydrocortisone (same structure as cortisol), prednisolone and dexamethasone, which have different immunosuppressive and metabolic properties; 10 mg hydrocortisone is roughly equivalent to 2.
0 mg prednisone Songlong or 0.
1 mg dexamethasone.

Dexamethasone has no mineralocorticoid activity and cannot provide hormone coverage under stress for patients with primary adrenal insufficiency.

 1.
Adult patients Table 1 Primary and secondary adrenal insufficiency recommended doses of intraoperative and postoperative hormone coverage for adult patients Table 2 There is a potential risk of adrenal suppression (prednisolone equivalent ≥ 5 mg, lasting ≥ 4 weeks) Recommended doses of intraoperative and postoperative hormone coverage for adults 2.
Perioperative management guidelines for children with adrenal insufficiency in children/adolescents cover children with primary adrenal insufficiency, including congenital adrenal hyperplasia and secondary adrenal function Incomplete children.

The infusion rate of hydrocortisone is based on cortisol clearance.

 Due to poor tolerance to fasting or dehydration, all patients with adrenal insufficiency should be arranged for the first surgery as much as possible.

If fasting for more than 4 hours before surgery, blood glucose should be monitored every hour.

The fasting time for children with adrenal insufficiency should not exceed 6 hours.

Children should take regular doses of hydrocortisone until surgery; or change to intravenous administration.

Blood glucose should be measured every hour after surgery until enteral nutrition is restored.

 All children with known glucocorticoid deficiency (primary/secondary) or at risk of glucocorticoid deficiency (receiving exogenous glucocorticoid >10-15 mg/m^2/d) should be in induction of general anesthesia Give hydrocortisone 2 mg/kg.

 Table 3 Recommended doses of intraoperative and postoperative hormone coverage for children with hypoadrenal function References: 1.
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