To the Editor:

Liu et al. provide a thorough review of perioperative steroid replacement and make evidence-based recommendations to help clear up the “confusing” recommendations about who needs “stress-dose” steroids, what agent to administer, and how much to administer.1  They report that there is limited evidence that such supplementation is necessary, but continue on to provide an algorithm for how much hydrocortisone to give at-risk patients based on anticipated surgical stress. They also point out that mineralocorticoid deficiency does not occur in secondary adrenal insufficiency (i.e., due to chronic exogenous steroid administration). They also indicate that administration of hydrocortisone can result in excess mineralocorticoid activity with resulting (and undesirable) fluid retention and hypokalemia.

The lack of evidence, clinical confusion, and adverse effects of hydrocortisone seem to beg for a simpler solution. As it happens, there is one: dexamethasone 4 (or 8) mg. The 30+ fold glucocorticoid potency compared with hydrocortisone, absence of mineralocorticoid activity, and longer half life seem to make it a superior agent for perioperative supplementation for any level of stress. Unlike the limited evidence of need for stress-dose steroids, or for an antiemetic effect of hydrocortisone, the evidence of efficacy and safety of dexamethasone for prevention of postoperative nausea/vomiting (PONV) is extensive.2,3  Since most of our patients have one or more risk factors for PONV, administering dexamethasone is usually indicated even without a question of adrenal insufficiency. Therefore, administering a PONV prophylaxis dose of dexamethasone seems like a simple, one-size-fits-all algorithm for dealing with any concern about secondary adrenal insufficiency.

References

References
1.
Liu
MM
,
Reidy
AB
,
Saatee
S
,
Collard
CD
:
Perioperative steroid management: Approaches based on current evidence.
Anesthesiology
2017
;
127
:
166
72
2.
Toner
AJ
,
Ganeshanathan
V
,
Chan
MT
,
Ho
KM
,
Corcoran
TB
:
Safety of perioperative glucocorticoids in elective noncardiac surgery: A systematic review and meta-analysis.
Anesthesiology
2017
;
126
:
234
48
3.
De Oliveira
GS
Jr
,
Castro-Alves
LJ
,
Ahmad
S
,
Kendall
MC
,
McCarthy
RJ
:
Dexamethasone to prevent postoperative nausea and vomiting: An updated meta-analysis of randomized controlled trials.
Anesth Analg
2013
;
116
:
58
74