Adrenal Insufficiency (AI)
ASSESSMENT
Data Gathering
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History
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Cause of adrenal insufficiency disease
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Recent glucocorticoid use
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Past, long-term glucocorticoid use
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Adrenal insufficiency or unexplained severe hypotension after previous surgery
Symptoms
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Fatigue
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Generalized weakness
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Weight changes
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Palpitations
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Edema
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Abdominal pain
Exam
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Orthostatic hypotension/tachycardia
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Skin hyperpigmentation
Risk Stratification
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Diagnostic Studies
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BMP within 6 months (or more recently if change in clinical status) if known or suspected AI
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Suspected AI:
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AM cortisol: if >10 mcg/dl, can rule out AI (Schmidt et al)
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ACTH-stimulation testing if adequate time to perform testing
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MANAGEMENT
Indications for Surgical Delay
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Elective surgery and suspected, undiagnosed adrenal insufficiency
Medication Management
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Very little evidence is available to guide the best perioperative management of adrenal insufficiency risk - recent review (Groleau et al) and Cochrane review found no evidence of benefit from "stress dose" steroids but too little data to refute the possible benefit
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Also no good evidence suggesting harm from administration of high-dose glucocorticoids for short periods (though hyperglycemia may occur)
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ACR/AAHKS guideline for perioperative management of rheumatoid arthritis patients specifically advises against "stress dose" steroids
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Majority of expert opinion provides recommendations similar to those shown in the table below
COUNSELING & COMMUNICATION
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​Educate patients with elevated BP that even though surgical delay may not be necessary, their long-term risk is increased, and they need follow-up