A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency

Cortisol response to general anaesthesia for medical imaging in children

OBJECTIVE

The cortisol response to surgical stress has been frequently studied, and recommendations developed for steroid replacement in adrenally insufficient patients. There are currently no guidelines, however, for adrenal hormone replacement during anaesthesia alone. The objective of this study was to characterize the normal cortisol response to general anaesthesia in the absence of a surgical procedure in children.

DESIGN

Prospective observational study.

PATIENTS

Thirty-seven children (aged 0.5-7 years) without known endocrine disease or cranial neoplasms undergoing outpatient magnetic resonance imaging, under general anaesthesia for investigation of nonacute problems in a tertiary referral paediatric hospital.

MEASUREMENTS

Serum cortisol and salivary cortisol were measured before and after anaesthesia and during recovery.

RESULTS

The mean cortisol level was 303 (± 117) nmol/l at induction, 396 (± 241) nmol/l at emergence from anaesthesia and 584 (± 218) nmol/l during recovery. A stress response (increase in serum cortisol >550 nmol/l) occurred in 23% of children at emergence and in 52% of children at recovery. Eight children (31%) actually demonstrated a decrease in cortisol levels during anaesthesia, without an increase in complications. Mean salivary cortisol levels were 6.5 ± 4.8 nmol/l before induction, 23.5 ± 13.8 nmol/l at emergence from anaesthesia and 26.9 ± 21.6 nmol/l during recovery. A stress response (an increase in salivary cortisol greater than seven-fold) occurred in 26% of children during the study.

CONCLUSIONS

While some children demonstrated a rise in their cortisol levels in response to anaesthesia without surgery, the response was variable and often more pronounced during recovery. There was consistently no classic stress response.

The new face of transplant surgery: a survey on cosmetic surgery in transplant recipients

BACKGROUND

Transplant surgery has undergone tremendous advances within the last decade. Improvements in surgical techniques, availability of potent immunosuppressive medications, and utilization of more sophisticated post-transplant immunosuppression protocols have revolutionized the field. These developments have resulted in increased allograft survival, prolonged longevity, and improved quality of life in transplant organ recipients. Elimination of steroids in many postoperative immunosuppressive regimens has tremendously impacted the quality of life and physical appearance of these patients. They are living longer and more normal lives than previously considered possible. As a testament to the success of transplantation surgery, many transplant patients are now seeking aesthetic surgery.

METHODS

A survey was sent to ASPS members asking about their experience with transplant patients undergoing aesthetic procedures.

RESULTS

Of the 789 (18%) plastic surgeons who responded, 201 (25%) have performed aesthetic surgery on transplant recipients. A total of 278 patients underwent 292 surgical aesthetic procedures and 64 patients underwent 94 nonsurgical aesthetic procedures. The incidence of reported perioperative complications was 3.4%. There were very few additional precautions taken with these patients relative to the general population. With the exception of obtaining medical clearance, these additional precautions were inconsistent among plastic surgeons.

CONCLUSION

Cosmetic surgery in transplant recipients is being successfully practiced in the USA. Surgical and nonsurgical aesthetic procedures are being performed safely in organ transplant recipients without a significant increase in the incidence or degree of complications. If certain precautions are undertaken, these patients may expect a degree of success comparable to that of the rest of the population.

Supplemental perioperative steroids for surgical patients with adrenal insufficiency

BACKGROUND

Adrenal crisis is a life threatening condition which can be induced by stress during surgery in patients with adrenal insufficiency. This may be prevented by perioperative administration of high doses of steroids. There is disagreement on whether supplemental perioperative steroids are required and, when administered, on the amount and frequency of doses.

OBJECTIVES

To assess whether it is necessary to administer supplemental perioperative steroids in adult patients on maintenance doses of glucocorticoids because of adrenal insufficiency.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 1); MEDLINE (1966 to January 2009); EMBASE (1980 to January 2009); LILACS (1982 to January 2009); and the databases of ongoing trials. We handsearched the Journal of Clinical Endocrinology and Metabolism (1982 to 1997), Clinical Endocrinology (1972 to 1997), Surgery (1948 to 1994), Annals of Surgery (1948 to 1994), and Anaesthesia (1948 to 2000).

SELECTION CRITERIA

Randomized, controlled trials that compared the use of supplemental perioperative steroids to placebo in adult patients on maintenance doses of steroids who required surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for missing information. We used mean differences and standard deviations to summarize the data for each group.

MAIN RESULTS

Two trials involving 37 patients were included. These studies reported that supplemental perioperative steroids were not required during surgery for patients with adrenal insufficiency. Neither study reported any adverse effects or complications in the intervention and control groups.

AUTHORS' CONCLUSIONS

Owing to the small number of patients, the results may not be representative. Based on current available evidence, we are unable to support or refute the use of supplemental perioperative steroids for patients with adrenal insufficiency during surgery.

The approach to the adult with newly diagnosed adrenal insufficiency

Adrenal insufficiency, primarily presenting as an adrenal crisis, is a life-threatening emergency and requires prompt therapeutic management including fluid resuscitation and stress dose hydrocortisone administration. Primary adrenal insufficiency is most frequently caused by autoimmune adrenalitis, and hypothalamic-pituitary tumors represent the most frequent cause of secondary adrenal insufficiency. However, the exact underlying diagnosis needs to be confirmed by a stepwise diagnostic approach, with an open eye for other differential diagnostic possibilities. Chronic replacement therapy with glucocorticoids and, in primary adrenal insufficiency, mineralocorticoids requires careful monitoring. However, current replacement strategies still require optimization as evidenced by recent studies demonstrating significantly impaired subjective health status and increased mortality in patients with primary and secondary adrenal insufficiency. Future studies will have to explore the potential of dehydroepiandrosterone replacement and modified delayed-release hydrocortisone to improve the prospects of patients with adrenal insufficiency.

Perioperative glucocorticosteroid supplementation is not supported by evidence

Ever since the first descriptions of adrenal insufficiency following exogenous supplementation physicians dread to abolish perioperative glucocorticosteroid supplementation. Now, 55 years after the first publications we can challenge those first reports. However, these cases have resulted in the supplementation of supraphysiological doses of glucocorticosteroids to patients that use exogenous corticosteroids: the so-called perioperative glucocorticosteroid supplementation or "(gluco)corticosteroid stress scheme". It is very questionable whether a dose that exceeds the normal daily production of 5.7 mg cortisol per square meter of body surface area is necessary to prevent perioperative hypotension. Retrospective, prospective and randomised studies, though all methodologically flawed, are discussed and show that continuation of the "basal" amount of glucocorticosteroids is sufficient to counterbalance surgical stress. The current and rather defensive strategy of perioperative supraphysiological glucocorticosteroid supplementation is not embedded in medical evidence. Additionally, high doses of glucocorticosteroids have disadvantages that should not be ignored.

Que reste-t-il de l'insuffisance surrénale post-corticothérapie?

Adrenal insufficiency (AI) induced by glucocorticoids was first described more than 50 years ago in patients undergoing surgical stress. Although considered the most frequent cause of AI, the true incidence of this complication of glucocorticoid treatment remains unknown. No factors are known to predict AI after glucocorticoid treatment. In particular, neither the dose nor the duration of treatment seems predictive. The minimum dose of cortisol necessary for the body to cope with medical or surgical stress is unknown. The adrenocorticotropin test is often used during corticosteroid withdrawal because it is well correlated with adrenal response to surgical stress, but not with clinical events. Studies over the past 15 years have shown that the perioperative risk of AI has been overestimated and that hydrocortisone doses should be decreased. A prospective study of patients after steroid withdrawal is the only means of assessing the true incidence of this complication to propose a rational strategy to prevent it.

Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment?

OBJECTIVES

To review published data on the perioperative management of antirheumatic treatment and perioperative outcome in patients with rheumatoid arthritis (RA).

METHODS

The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords "rheumatoid arthritis" and "surgery". As co-indexing terms the different disease-modifying antirheumatic drugs (DMARDs) as well as nonsteroidal anti-inflammatory drugs (NSAIDs) and "glucocorticoids" were used. In addition, citations from retrieved articles were scanned for additional references. Furthermore, because the number of published articles is so limited, relevant abstracts presented at congresses were included in the analysis.

RESULTS

Continuation of methotrexate (MTX) appears to be safe in the perioperative period. Only a limited number of studies address the use of leflunomide and the results are conflicting. Because of the very long drug half-life, its discontinuation would need to be of long duration and is probably not necessary. Data on hydroxychloroquine do not show increased risks of infection. Regarding sulfasalazine, there are no studies from which definite answers could be drawn on whether it should be withheld perioperatively. Preliminary data show that the risk of infections during treatment with TNF-blocking agents may be lower than initially expected. The only available recommendation (Club Rhumatismes et Inflammation, CRI) suggests discontinuing the drugs before surgery for several weeks, depending on the risk of infection and the drug used. They should not be restarted until wound healing is complete. To avoid the antiplatelet effect during surgery, NSAIDs other than aspirin should be withheld for a duration of 4 to 5 times the drug half-life. Patients with chronic glucocorticoid therapy and suppressed hypothalamic-pituitary-adrenal (HPA) axis need perioperative supplementation.

CONCLUSIONS

While continuation of MTX likely is safe, data on other DMARDs are sparse. In particular, more data on the perioperative use of the biologic agents are needed.

The Preoperative Evaluation of the Transplanted Patient for Nontransplant Surgery

With the improved success of solid-organ transplantation, there has been an increased willingness to transplant individuals previously felt to be unsuitable for such procedures. Factors such as age and various medical comorbidities are no longer considered contraindications to transplantation, and hence, an increasing number of recipients may require medical care not specifically related to the transplant. After transplantation, many of these patients may require elective or emergent surgery, making it important for all surgeons to be familiar with the factors that may influence surgical outcomes in this population, asa well asa factors that affect postoperative care. Most transplant centres use a team approach to manage these complex patients, relying on medical professionals experienced in their care and management. Close interaction with the transplant team is likely the single most important step in preparing the transplanted patient for surgery and managing their postoperative care.

Therapeutic doses of glucocorticoids: implications for oral medicine

Glucocorticoids can cause adverse systemic side-effects ranging from iatrogenic Cushing's syndrome during treatment, to hypothalamic-pituitary-adrenal axis suppression and clinically significant adrenal insufficiency when the agents are discontinued. While the oral route of administration is most often implicated, it is now becoming more apparent that inhaled and topical administration also can cause these effects. Given the high therapeutic value of glucocorticoids, the ability to prescribe these agents while maintaining a low risk-to-benefit ratio for patients is critical. The aim of this review is to provide oral healthcare practitioners with a practical guide to commonly used glucocorticoids, their adverse effects, and perioperative use.

Perioperative management of medications used in the treatment of rheumatoid arthritis

Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.

The Hypothalamic-Pituitary-Adrenal Axis in Critical Illness

Severe stress, associated with critical illness, activates the hypothalamic- pituitary-adrenal (HPA) axis and stimulates the release of cortisol from the adrenal cortex. Cortisol is essential for general adaptation to stress and plays a crucial role in cardiovascular, metabolic, and immunologic homeostasis. During critical illness, prolonged activation of the HPA axis can result in hypercortisolemia and hypocortisolemia; both can be detrimental to recovery from critical illness. Recognition of adrenal dysfunction in critically ill patients is difficult because a reliable history is not available and laboratory results are difficult to interpret. The review in this article will illustrate how adrenal dysfunction presents in critically ill patients and how appropriate diagnosis and management can be achieved in the critical care setting.

Management of adrenal insufficiency in different clinical settings

Adrenal insufficiency is a rare disease, but its prevalence is increasing. The most frequent cause of primary adrenal insufficiency in western countries is autoimmune adrenalitis, whereas secondary adrenal insufficiency is most often caused by pituitary tumours and their treatment (e.g., surgery). Chronic glucocorticoid replacement consists of hydrocortisone 15-25 mg/day in divided doses and dose monitoring is largely based on clinical judgement. Fludrocortisone 0.05-0.2 mg/day is given for substitution in mineralocorticoid deficiency aiming at normotension, normokalaemia and a plasma renin activity in the upper normal range. It has recently been shown that, despite adequate glucocorticoid and mineralocorticoid replacement well being in patients with adrenal insufficiency is still impaired. Several studies have demonstrated that dehydroepiandosterone 25-50 mg/day p.o. may improve mood, fatigue, well-being and, in women, also sexuality, suggesting that dehydroepiandosterone should become part of the standard treatment regime. However, large Phase III trials of dehydroepiandosterone for adrenal insufficiency are still lacking and it has not yet been approved for the treatment of this disease. Patients with adrenal insufficiency are at risk of adrenal crisis, usually precipitated by major stress, such as severe infection or surgery. Early dose adjustments are required to cover the increased glucocorticoid demand in stress. Careful and repeated education of patients and their partners is the best strategy to avoid this life-threatening emergency. Some recent studies suggest that during sepsis some patients with intact adrenal function may develop transient relative adrenal insufficiency and benefit from administration of hydrocortisone plus fludrocortisone. However, the pathophysiology and diagnosis criteria of relative adrenal insufficiency and its treatment remain unsettled issues.

[Adrenal cortex and steroids. Supplementary therapy in the perioperative phase]

Since the publication of two case reports that are considered to represent the first clinical demonstration of iatrogenic adrenal insufficiency, it has been the generally accepted practice to cover steroid-treated patients undergoing surgery with glucocorticoids in the perioperative period. Both the inclusion criteria for the patients and the extent of the substitution pattern have been selected on an empirical rather than on a rational basis. Scientific advances over the past 50 years in the knowledge of the hypothalamic-pituitary-adrenal system's physiology and the molecular mechanism of action of its biologically active components are, for the most part, not reflected in current clinical practice and instead seem to be ignored. Clinical and experimental evidence suggests, however, that even glucocorticoid-treated patients undergoing surgery do not require maximum stress doses of hydrocortisone, which should be reserved for the treatment of sepsis. With regard to the broad spectrum of efficacy of glucocorticoids and their side effects, revision and modification of the historical regimen appear prudent.

Exogenous Cushing's syndrome and glucocorticoid withdrawal

Glucocorticoid therapy in various forms is extremely common for a wide range of inflammatory, autoimmune, and neoplastic disorders. It is therefore important for the physician to be aware of the possibility of both iatrogenic and factitious Cushing's syndrome. Although most common with oral therapy, it is also important to be alert to the fact that all forms of glucocorticoid delivery have the potential to cause Cushing's syndrome. Withdrawal from chronic glucocorticoid therapy presents significant challenges. These include the possibility of adrenal insufficiency after discontinuation of steroid therapy, recurrence of underlying disease as the glucocorticoid is being withdrawn, and the possibility of steroid withdrawal symptoms. Nonetheless, with patience and persistence, a reasonable approach to withdrawal of glucocorticoid therapy can be achieved.

Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature

Based to a great extent upon mainly anecdotal case reports and theory, there is a general acceptance that patients on long-term systemic steroid medication should receive supplementary glucocorticoids or "steroid cover" when undergoing certain types of stressful treatment including dentistry. The theoretical basis to this practice is that exogenous steroids suppress adrenal function to an extent that insufficient levels of cortisol can be produced in response to stress, posing the risk of acute adrenal crisis with hypotension and collapse. The purpose of this paper is to review relevant literature and propose clinical guidelines for dental practitioners. Of numerous reported cases of adrenal crisis following procedural interventions, few stand up to critical evaluation. Other reviewers have reached similar conclusions. A number of studies confirm the low likelihood of significant adrenal insufficiency even following major surgical procedures. Various authors have suggested modified guidelines for management of patients on steroid medications. Patients on long-term steroid medication do not require supplementary "steroid cover" for routine dentistry, including minor surgical procedures, under local anaesthesia. Patients undergoing general anaesthesia for surgical procedures may require supplementary steroids dependent upon the dose of steroid and duration of treatment.

Critical issues in endocrinology

Endocrine emergencies are commonly encountered in the ICU. This article focuses on several important endocrine emergencies, including diabetic hyperglycemic states, adrenal insufficiency, myxedema coma, thyroid storm, and pituitary apoplexy. Other endocrine issues that are related to intensive care, such as intensive insulin therapy, relative adrenal insufficiency, and thyroid function test abnormalities are also covered in detail.

Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty

BACKGROUND

There is controversy about whether patients who take exogenous glucocorticoids, such as prednisone, require supplemental (exogenous) glucocorticoids in order to meet the physiological demands of surgery. In this study, we sought to define the magnitude of the surgical stress response in normal patients undergoing major and minor elective orthopaedic surgery.

METHODS

A prospective, observational study of thirty patients who had not taken exogenous glucocorticoids and who underwent either elective knee arthroscopy or elective unilateral total knee arthroplasty was performed. Regional anesthesia was used for all patients, and all patients treated with total knee arthroplasty had continuous epidural anesthesia for forty-eight hours after the surgery. The stress response was assessed on the basis of serum and twenty-four-hour urine cortisol levels; comparisons of the urine values were made after correcting for renal function by calculating the cortisol-to-creatinine clearance ratio.

RESULTS

Preoperatively, patients undergoing arthroscopy and total knee arthroplasty had similar cortisol-to-creatinine clearance ratios. Patients treated with total knee arthroplasty had a significant (p < 0.001) surgical stress response on the day of the surgery, compared with baseline, whereas patients treated with arthroscopy did not. The mean cortisol-to-creatinine clearance ratio in patients treated with total knee arthroplasty was highest on the day of the surgery and decreased on the third postoperative day. However, on the third postoperative day, the cortisol-to-creatinine clearance ratio still was significantly higher than the baseline value (p < 0.001). Significant differences in the serum cortisol levels also were detected between the patients treated with arthroscopy and those treated with total knee replacement.

CONCLUSIONS

Patients undergoing total knee arthroplasty had a significant surgical stress response (a seventeenfold increase in the cortisol-to-creatinine clearance ratio); patients treated with arthroscopy did not. Additional studies, including a prospective trial of patients taking exogenous glucocorticoids, are warranted. Until they are performed, the significantly increased cortisol production observed in non-steroid-dependent patients following total knee arthroplasty leaves open the possibility that steroid-dependent patients undergoing this procedure could benefit from perioperative glucocorticoid supplementation. Since the non-steroid-dependent patients in the present series did not mount a substantial stress response to knee arthroscopy, our results do not support the use of supplemental steroids for that less-invasive procedure.

Perioperative management of patients treated with glucocorticoids

HPA suppression is a common consequence of glucocorticoid therapy, whereas overt secondary adrenal insufficiency is a rare but life-threatening condition. Prolonged hypotension and a response to adequate doses of a glucocorticoid agent are not reliable ways to assess adrenocortical function. One must also demonstrate plasma cortisol levels that are inappropriately low for the clinical situation. Hypotension in patients previously treated with glucocorticoids is caused by loss of the permissive effect of glucocorticoids on vascular tone, which may be related in turn to enhanced PGI2 production in the absence of glucocorticoids. It is not caused by mineralocorticoid deficiency. Recurrent problems of study design and interpretation have plagued this area of investigation. Any patient who has received a glucocorticoid in doses equivalent to at least 20 mg a day of prednisone for more than 5 days is at risk for HPA suppression. If the doses are closer to but above the physiologic range, 1 month is probably the minimal interval. Recovery from prolonged exposure to high doses of glucocorticoids may take up to 1 year. Pituitary function returns before adrenocortical function. Recovery from short courses of treatment (e.g., 5 days) occurs more rapidly, in about 5 days. Recovery is time-dependent and spontaneous. The rate of recovery is a function of the dose and duration of therapy before tapering is started and while the dose is being reduced. ACTH therapy does not cause adrenocortical suppression but offers no advantage over glucocorticoids, has several disadvantages, and should no longer be used. Patients on alternate day glucocorticoid therapy have some suppression of basal cortisol levels but have normal or nearly normal responses to provocative tests of adrenocortical function. The standard short ACTH stimulation test is a reliable means of assessing adrenocortical function preoperatively. The low dose (1 microgram) short ACTH test is promising but has not been sufficiently well characterized, requires serial dilutions and cannot be recommended at this time. Studies of the physiologic adrenocortical response to surgical stress provide a basis for revised dose recommendations for perioperative coverage in the patient with known or suspected HPA suppression. Recommendations of a multidisciplinary group are presented.

Adrenal insufficiency

Adrenal insufficiency is caused by either primary adrenal failure (mostly due to autoimmune adrenalitis) or by hypothalamic-pituitary impairment of the corticotropic axis (predominantly due to pituitary disease). It is a rare disease, but is life threatening when overlooked. Main presenting symptoms such as fatigue, anorexia, and weight loss are non-specific, thus diagnosis is often delayed. The diagnostic work-up is well established but some pitfalls remain, particularly in the identification of secondary adrenal insufficiency. Despite optimised life-saving glucocorticoid-replacement and mineralocorticoid-replacement therapy, health-related quality of life in adrenal insufficiency is more severely impaired than previously thought. Dehydroepiandrosterone-replacement therapy has been introduced that could help to restore quality of life. Monitoring of glucocorticoid-replacement quality is hampered by lack of objective methods of assessment, and is therefore largely based on clinical grounds. Thus, long-term management of patients with adrenal insufficiency remains a challenge, requiring an experienced specialist. However, all doctors should know how to diagnose and manage suspected acute adrenal failure.

Perioperative evaluation and management of the patient with endocrine dysfunction

Whenever possible, endocrine disorders should be identified and evaluated prior to surgery. A plan for perioperative management of diabetes should be based on the type of diabetes, what diabetes medications are taken, the status of diabetes control, and what type of surgery is planned. Perioperative management of diabetes must include bedside glucose monitoring. Patients with mild hypothyroidism can safely proceed with elective surgery. Elective surgery should be postponed for patients with moderate or severe hypothyroidism. Patients who have mild hyperthyroidism can undergo elective surgery with preoperative beta blockade. Elective surgery should not be done on patients with moderate or severe hyperthyroidism until they are euthyroid. Patients with pheochromocytoma need to be identified and properly treated before surgery to prevent perioperative cardiovascular complications. Patients who take endogenous steroids should have the status of their HPA axis determined prior to surgery. If the patient is undergoing moderate or major surgical stress and has documented or presumed HPA suppression, then stress doses of steroids should be give perioperatively.

Endocrine and metabolic issues in the management of the chronically critically ill patient

The metabolic syndrome of chronic critical illness (CCI) consists of multisystem organ dysfunction resulting from the initial acute injury and chronic immune-neuroendocrine axis activation, adult kwashiorkor-like malnutrition, and prolonged immobilization with suppression of the PTH-vitamin D axis and hyper-resorptive metabolic bone disease. CCI patients can also present unique challenges in the management of diabetes mellitus, thyroid and adrenal diseases, electrolyte abnormalities and hypogonadism.

Surgery and the patient with arthritis

Patients with rheumatologic disease (e.g., arthritis) require special attention when surgery is considered. Proactive attention to medication usage, corticosteroid coverage, airway, respiratory, joint stability and fragility challenges, cold exposure, and coagulation risks facilitate surgical intervention for such individuals.

Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsideration of the problem

BACKGROUND

Dental patients with primary or secondary adrenal insufficiency, or AI, may be at risk of experiencing adrenal crisis during or after invasive procedures. Since the mid-1950s, supplemental steroids in rather large doses have been recommended for patients with AI to prevent adrenal crisis.

METHODS

To evaluate the need for supplemental steroids in these patients, the authors searched the literature from 1966 to 2000 using MEDLINE and textbooks for information that addressed AI and adrenal crisis in dentistry. Reference lists of relevant publications and review articles also were examined for information about the topic.

RESULTS

The review identified only four reports of purported adrenal crisis in dentistry. Factors associated with the risk of adrenal crisis included the magnitude of surgery, the use of general anesthetics, the health status and stability of the patient, and the degree of pain control.

CONCLUSIONS

The limited number of reported cases strongly suggests that adrenal crisis is a rare event in dentistry, especially for patients with secondary AI, and most routine dental procedures can be performed without glucocorticoid supplementation.

CLINICAL IMPLICATIONS

The authors identify risk conditions for adrenal crisis and suggest new guidelines to prevent this problem in dental patients with AI.

Perioperative management of selected endocrine disorders

Anesthesiologists routinely encounter patients with endocrine disorders. Good perioperative outcome depends on preoperative identification, risk stratification and optimization of the patients' endocrinopathies and their sequelae; intraoperative control of metabolic and physiological parameters; and appropriate postoperative pain management, stress modulation, and evaluation of neurological, cardiovascular, and renal function.

Endocrine problems in the chronically critically ill patient

The endocrine adaptations to critical illness are varied. In the diabetic patient, counterregulatory hormones predispose to insulin resistance and hyperglycemia, a derangement accentuated by the use of glucocorticoids and enteral or parenteral nutrition. Thyroid abnormalities include the euthyroid sick syndrome, which may manifest as a low T3, low T4, low TSH, or all three. Illness in patients with pre-existing hypothyroidism or hyperthyroidism may precipitate myxedema coma or thyroid storm, respectively. The most important issue related to calcium is that of acute hypercalcemia, which, in the intensive care unit, usually is caused by malignancy and dehydration. Hyponatremia, a frequently encountered electrolyte disturbance, is evaluated best and treated according to volume status.

Perioperative management of selected problems in patients with rheumatic diseases

Patients undergoing surgery are subject to multiple perioperative problems. This article reviews several issues that occur in surgical patients with rheumatic diseases, including management of medications, diagnosis of fat embolism syndrome, prophylaxis against endocarditis, postoperative fever, and perioperative myocardial infarction.