Medical and endocrine disease06 / 30
Long-term steroid therapy for total hip replacement78-year-old woman, 58 kg, for elective left cemented total hip arthroplasty
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Know this first
- Prednisone above 20 mg/day for over 3 weeks within the past year: supplement. Between 5 and 20 mg: probably supplement.
- Secondary adrenal suppression lacks glucocorticoid only; mineralocorticoid is preserved.
- Moderate surgery: 50–75 mg IV hydrocortisone that day on top of her usual dose; baseline again within 1–2 days.
- Intraoperative adrenal crisis: hydrocortisone 100 mg IV, fluid and vasopressors; avoid etomidate.
The patient
78-year-old woman, 58 kg, for elective left cemented total hip arthroplasty.
Polymyalgia rheumatica on prednisolone 15 mg daily for 2 years; thin, bruised skin; osteoporotic wrist fracture last year.
Her morning prednisolone was missed on admission. Other drugs: alendronate, omeprazole.
Vitals: BP 132/78, HR 76, SpO2 96% on air, RR 14; Na 133 mmol/L, glucose 104 mg/dL.
The examiner asks
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Consider
What are your considerations?
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- A 78-year-old on prednisolone 15 mg daily for two years, for elective cemented hip replacement. Patient
- At 78 I screen her frailty and cognition, and plan reduced, titrated induction doses.
- At 15 mg daily, between 5 and 20, her axis may be suppressed; I treat it as suppressed. Disease
- Her suppression is secondary: she lacks cortisol, but her mineralocorticoid is usually intact.
- Missing this morning's dose takes away even her baseline steroid on the day of surgery. Stem trigger
- Thin skin and osteoporosis: careful handling and padding when we position her. Surgery
Prepare
How do you prepare her?
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- Her usual prednisolone 15 mg is given this morning, by mouth or as an IV equivalent. Disease
- Hip replacement is moderate stress, so she also gets hydrocortisone 50–75 mg IV that day.
- Then tapered back to her usual dose over 1–2 days. After surgery
- Her sodium of 133 and her glucose are rechecked; low sodium can point to adrenal insufficiency. Disease
- Etomidate is avoided because it blocks cortisol synthesis.
Plan
What is your anaesthetic plan?
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- No technique is specifically preferred for adrenal suppression; I choose by her hip and her frailty. Disease
- If GA, propofol below 1.5 mg/kg, titrated; larger doses cause severe hypotension at her age. Patient
- Arterial line before cementing: cement implantation can cause sudden hypotension and hypoxia. Surgery
- Pressure points padded and tape kept off her fragile skin.
- On the ward, glucose and sodium checks while her steroid is tapered. After surgery
Crisis
Ten minutes after induction her BP is 64/36, HR 98. Repeated phenylephrine and ephedrine barely move it. What do you do?
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- Vasopressor-resistant hypotension in a steroid-dependent woman: acute adrenal insufficiency until proven otherwise. Crisis
- I exclude the others quickly: anaesthetic depth, bleeding, anaphylaxis, and cement if it's in.
- Hydrocortisone 100 mg IV immediately, repeated 6-hourly.
- Not dexamethasone: it has no mineralocorticoid action to support her circulation.
- Fluid boluses; her deficit may be 2–3 litres.
- Noradrenaline 0.05–0.3 mcg/kg/min while the steroid acts, glucose and potassium checked.
- HDU afterwards; the steroid is reduced to oral once she's stable. After surgery
Fatal mistakes
- Escalating vasopressors without giving hydrocortisone.
- No steroid cover around surgery despite two years of prednisolone.
- Blaming the hypotension on anaesthetic depth alone.
Checked against: Stoelting 8e · Miller 10e
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