A patient on chronic corticosteroid therapy undergoing surgery is at risk of which acute crisis?

• A. Adrenal hypertrophy
• B. Thyroid storm
• C. Hyperglycemic hyperosmolar state
• D. Addisonian crisis

Answer: (D)

During surgery the body needs cortisol to cope with stress. Chronic corticosteroid use suppresses the hypothalamic-pituitary-adrenal axis, causing the adrenal glands to atrophy. In the perioperative period, the demand for cortisol rises, but endogenous production is blunted. Without enough cortisol, vascular tone and glucose regulation falter, which can lead to acute adrenal insufficiency known as Addisonian crisis. This presents with severe hypotension (often not responsive to fluids), tachycardia, abdominal pain, nausea/vomiting, fever, and possible hypoglycemia or hyponatremia. The key protective measure is providing stress-dose steroids during surgery to prevent this crisis.