Steroid precautions for hypoadrenal patients undergoing surgery or other procedures

Patients with hypoadrenalism of any cause require special precautions before undergoing invasive procedures. This advice applies to patients with Addison's disease, hypopituitarism, or long term adrenal suppression and covers procedures such as endoscopy, dental work and major surgery.

Random cortisol

It is useful to send a random cortisol immediately in patients presenting acutely unwell before starting emergency glucocorticoid therapy. It is not necessary to perform a Synacthen test or other investigations as to possible underlying cause at this time.

However, patients with known adrenal insufficiency of any cause who are already on treatment do not require any additional evaluation of their cortisol levels prior to procedures. 

Full blood count

This is a useful indicator of general health and underlying disease, and essential in the collapsed patient.

Macrocytosis may be seen with profound hypothyroidism, but may reflect undiagnosed pernicious anaemia.

Normocytic normochromic anaemia and eosinophilia may be seen with glucocorticoid deficiency.

Urea and electrolytes

Hyponatraemia and hyperkalaemia are commonly seen in undertreated hypoadrenalism, but urea and electrolytes should be normal in most treated patients.

Baseline urea and electrolytes are useful in a patient likely to be nil by mouth for a prolonged peroid or likely to require intra-venous fluids or prolonged intr-muscular hydrocortisone as hypokalaemia may occur.

Thyroid function testing

Autoimmune thyroid dysfunction is commonly associated with Addison's disease. It may therefore be prudent to rule this out in high risk patients prior to major procedures.