Alana E. Sigmund, MD and Jason F. Shiffermiller, MD, MPH

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Summary

Surgery in patients with primary adrenal insufficiency can precipitate acute adrenal insufficiency, a potentially life-threatening complication. Acute adrenal insufficiency, however, can be prevented by the perioperative administration of a short course of stress dose steroids. Patients with secondary adrenal insufficiency due to exogenous steroid administration may also be at risk for perioperative acute adrenal insufficiency due to suppression of the hypothalamic-pituitary-adrenal axis. When these patients present for preoperative evaluation, the risk for acute adrenal insufficiency must be weighed against the risk of administering higher steroid doses in the perioperative period. Inconsistencies in the published literature and the widespread use of perioperative dexamethasone can make decisions about perioperative stress dose steroid administration challenging. The following module suggests a rational strategy for the perioperative management of both patients with known adrenal insufficiency and those at risk for hypothalamic-pituitary-adrenal axis suppression due to exogenous steroid administration.

Learning Objectives

After completing this module, the participant should be able to:

1. Differentiate primary and secondary adrenal insufficiency with regard to etiology, pathophysiology, and presentation.
2. Categorize exogenous steroids by their relative glucocorticoid and mineralocorticoid potency.
3. Risk-stratify patients for perioperative acute adrenal insufficiency based on the combination of patient-specific risk and degree of surgical stress.
4. Selectively order preoperative hypothalamic-pituitary-adrenal axis testing.
5. Use a risk matrix to develop a perioperative steroid management plan.
6. Consider the implications of perioperative dexamethasone administration on the stress steroid management plan.

Accreditation Statement

The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Statement Designation

The Society of Hospital Medicine designates this live activity for a maximum of 2.00 AMA PRA Category 1 Credit^TM.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

Conflict of Interest Disclosure Policy

In accordance with the ACCME Standards for Commercial Support, SHM requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. SHM mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs. All relevant financial relationships shall be disclosed to participants prior to the start of the activity.

Furthermore, SHM seeks to verify that all scientific research referred to, reported, or used in a continuing medical education (CME) activity conforms to the generally accepted standards of experimental design, data collection, and analysis. SHM is committed to providing its learners with high-quality CME activities that promote improvements in healthcare and not those of a commercial interest.

Instructions

The following is an interactive educational module designed to help you gauge your basic knowledge of the topic and then direct you to areas you may need to focus on. It consists of several sections: a pre-test, a study program, a post-test and a CME evaluation. All sections must be completed to receive CME credit.