Systemic Steroids

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    *Steroid equivalents: 5mg prednisone = 4mg methylprednisolone =0.75 mg dexamethasone = 20mg hydrocortisone
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    Stress Dose of Steroids

    • It is thought that those receiving > 5mg of prednisone daily > 3 weeks develop adrenal suppression.
    • Whenever the person is subjected to stress (surgery, sepsis, etc..) their steroid requirement goes up. (physiologic dose of steroids is 10-12mg of hydrocortisone equivalent daily, can go up to as much as 100-150mg).
    • Those with adrenal suppression are unable to respond to increased stress.  In the setting of a "stressor" (surgery, trauma, sepsis), they can develop adrenal insufficiency, which can lead to hypotension, hypoglycemia, electrolyte disturbances, worsening shock, and death.
    • Often people with adrenal insufficiency (or on steroids) present hypotensive, tachycardic, febrile, and decreased LOC are likely adrenally insufficient (all symptoms including fever are of adrenal insufficiency).
    • Those on chronic steroids are educated the "3x3 rule": Triple oral steroid dose for 3 days in the setting of a chronic illness.
    • If admitted to hospital, they often require 100mg of IV hydrocortisone (1:1 mineral:glucocorticoid activity) x3 days.
    • Evidence:
      • There were two published case reports in 1950 of young patients with adrenal suppression dying after a routine ortho surgery.  
      • Currently no evidence to support stress dosing.  Some evidence to show that it is not helpful, but evidence is weak (i.e. 17 patients randomized trial) and there have not been any convincing trials. 
      • See attached article on stress doing.
    • See attached page on one set of guidelines for stress dosing.