Endocrine Checklists in Perioperative Medicine: A Comprehensive Guide for Critical Care Practitioners

Dr Neeraj Manikath , claude.ai

Abstract

Background: Perioperative endocrine management represents a critical component of surgical care, with inadequate attention to endocrine pathophysiology contributing significantly to perioperative morbidity and mortality. This review provides evidence-based checklists and practical guidance for managing adrenal suppression, diabetes control, thyroid optimization, and steroid coverage in the perioperative period.

Methods: Comprehensive literature review of current guidelines from major endocrine and anesthetic societies, recent meta-analyses, and landmark studies in perioperative endocrine medicine.

Results: Structured checklists and decision algorithms can significantly improve perioperative outcomes by ensuring systematic evaluation and management of endocrine disorders. Key areas include recognition of occult adrenal insufficiency, optimization of glycemic control, perioperative thyroid management, and appropriate stress-dose steroid protocols.

Conclusions: Implementation of standardized endocrine checklists in perioperative medicine can reduce complications, improve patient safety, and optimize surgical outcomes through systematic, evidence-based management protocols.

Keywords: Perioperative medicine, endocrine disorders, adrenal insufficiency, diabetes mellitus, thyroid disease, steroid coverage, critical care

Introduction

The perioperative period represents a state of profound physiological stress, challenging the body's endocrine regulatory mechanisms and potentially unmasking subclinical endocrine disorders. With the increasing complexity of surgical procedures and an aging population with multiple comorbidities, systematic attention to endocrine pathophysiology has become paramount for optimal perioperative outcomes.

Endocrine disorders affect approximately 15-20% of surgical patients, yet are frequently overlooked or inadequately managed in the perioperative setting. The stress response to surgery, anesthesia, and critical illness can precipitate life-threatening endocrine crises in susceptible individuals, making preoperative identification and optimization crucial.

This review presents evidence-based checklists and practical algorithms for managing the four most critical endocrine considerations in perioperative medicine: adrenal suppression, diabetes control, thyroid optimization, and steroid coverage protocols.

1. Adrenal Suppression: Recognition and Management

Pathophysiology and Clinical Significance

Adrenal insufficiency (AI) in the perioperative period can be primary (Addison's disease), secondary (pituitary dysfunction), or tertiary (exogenous steroid suppression). The most common cause in surgical patients is suppression of the hypothalamic-pituitary-adrenal (HPA) axis from chronic corticosteroid use.

Pearl: Even low-dose topical or inhaled steroids can cause clinically significant HPA suppression, particularly with prolonged use or in elderly patients.

Preoperative Assessment Checklist

Risk Factor Identification:

[ ] History of steroid use (any route, duration >3 weeks in past year)
[ ] Clinical signs: hyperpigmentation, weakness, weight loss
[ ] Previous diagnosis of AI or pituitary disorders
[ ] Autoimmune conditions (especially autoimmune polyglandular syndromes)
[ ] Recent cessation of chronic steroid therapy
[ ] History of unexplained perioperative hypotension

Diagnostic Considerations:

[ ] Morning cortisol <3 μg/dL (83 nmol/L): definitive AI
[ ] Morning cortisol 3-15 μg/dL (83-414 nmol/L): consider stimulation testing
[ ] ACTH stimulation test if intermediate cortisol levels
[ ] Consider random cortisol if emergency surgery

Oyster Alert: Normal baseline cortisol does not exclude AI in critically ill patients due to altered cortisol-binding proteins and tissue resistance.

Perioperative Management Protocol

Preoperative Optimization:

Confirmed AI patients:
- Continue maintenance therapy until surgery
- Ensure adequate mineralocorticoid replacement
- Optimize fluid and electrolyte balance
Suspected AI (pending confirmation):
- Obtain baseline cortisol before steroid administration
- Initiate stress-dose steroids if high clinical suspicion

Intraoperative Management:

Minor Surgery (local anesthesia, brief procedures):

Continue usual steroid dose
No additional coverage typically needed

Moderate Surgery (regional anesthesia, intermediate procedures):

Hydrocortisone 50-75 mg IV at induction
Continue usual dose postoperatively

Major Surgery (general anesthesia, extensive procedures):

Hydrocortisone 100-150 mg IV at induction
Hydrocortisone 50-100 mg IV q8h for 24-48 hours
Taper to maintenance over 2-3 days

Clinical Hack: Use the "rule of 100s" - 100 mg hydrocortisone at induction for major surgery, then 100 mg daily divided q8h, tapering by 50% daily until maintenance dose reached.

Postoperative Monitoring

Critical Parameters:

[ ] Hemodynamic stability (BP, HR trends)
[ ] Electrolyte balance (Na+, K+, glucose)
[ ] Signs of AI crisis: hypotension, hyperkalemia, hypoglycemia
[ ] Wound healing and infection surveillance
[ ] Stress response adequacy

Management of Suspected AI Crisis:

Immediate IV access and fluid resuscitation
Hydrocortisone 100 mg IV bolus, then 200-300 mg/24h continuous infusion
Aggressive fluid and electrolyte correction
Vasopressor support if needed
Search for and treat precipitating factors

2. Diabetes Control: Perioperative Glycemic Management

Clinical Impact and Goals

Perioperative hyperglycemia is associated with increased infection rates, delayed wound healing, prolonged hospital stay, and increased mortality. Conversely, severe hypoglycemia can cause neurological damage and cardiac arrhythmias.

Target Ranges:

Non-critical care: 140-180 mg/dL (7.8-10.0 mmol/L)
Critical care: 140-180 mg/dL (avoiding <70 mg/dL)
Cardiac surgery: 120-160 mg/dL for first 24-48 hours

Preoperative Assessment Checklist

Baseline Evaluation:

[ ] HbA1c level (target <7% for elective surgery if possible)
[ ] Current medications and adherence
[ ] History of hypoglycemic episodes
[ ] Presence of diabetic complications (nephropathy, neuropathy, CAD)
[ ] Baseline renal function (creatinine, eGFR)
[ ] Infection screening

Medication Review:

[ ] Metformin: hold 24-48 hours pre-op if contrast exposure or renal concerns
[ ] SGLT2 inhibitors: discontinue 3 days before surgery (DKA risk)
[ ] Insulin requirements and timing
[ ] Other antihyperglycemic agents: individualized approach

Pearl: Preoperative HbA1c >8.5% is associated with significantly increased perioperative complications and should prompt delay of elective procedures for optimization when possible.

Perioperative Management Protocols

Type 1 Diabetes Management:

Preoperative:

Continue basal insulin (reduce by 20-25% if NPO)
Hold rapid-acting insulin with last meal
Start dextrose-containing IV fluids if prolonged NPO

Intraoperative:

Continuous insulin infusion for procedures >2 hours
Target glucose 140-180 mg/dL
Monitor glucose hourly

Type 2 Diabetes Management:

Diet-controlled or metformin only:

Monitor glucose q6h perioperatively
Initiate insulin if glucose >180 mg/dL

Insulin-requiring:

Continue 75-80% of basal insulin if NPO
Hold prandial insulin
Use correction insulin protocol

Clinical Hack - "The 80% Rule": For patients on basal insulin who are NPO, give 80% of their usual basal dose and start dextrose-containing IV fluids. This maintains glycemic control while preventing hypoglycemia.

Intensive Care Unit Protocols

Continuous Insulin Infusion Guidelines:

Starting insulin infusion (regular human insulin):

BG 140-199 mg/dL: 0.5 units/hour
BG 200-249 mg/dL: 1.0 units/hour
BG 250-299 mg/dL: 1.5 units/hour
BG ≥300 mg/dL: 2.0 units/hour

Adjustment Protocol:

Check BG hourly until stable, then q2h
Adjust insulin rate by 0.5-1.0 units/hour based on BG trends
If BG <70 mg/dL: stop insulin, give dextrose, recheck in 15 minutes

Oyster Alert: Insulin requirements can increase dramatically during stress, infection, or steroid administration. Don't hesitate to escalate insulin doses appropriately.

Postoperative Transition

ICU to Floor Transfer:

Ensure stable glycemic control on current regimen
Calculate total daily insulin requirements from infusion
Transition using 50% as basal, 50% as nutritional coverage
Continue frequent monitoring initially

3. Thyroid Optimization: Perioperative Considerations

Clinical Significance

Unrecognized thyroid disorders can significantly impact perioperative outcomes. Hyperthyroidism increases risks of arrhythmias, heart failure, and thyroid storm, while severe hypothyroidism can cause delayed drug metabolism, hypothermia, and cardiovascular instability.

Preoperative Assessment Checklist

Clinical Screening:

[ ] Symptoms: palpitations, weight changes, heat/cold intolerance
[ ] Physical examination: goiter, tremor, eye signs, skin changes
[ ] Cardiovascular assessment: AF, heart failure signs
[ ] Medication history: antithyroid drugs, levothyroxine, iodine

Laboratory Assessment:

[ ] TSH (most sensitive screening test)
[ ] Free T4 and T3 if abnormal TSH
[ ] Consider in high-risk patients: elderly, cardiac surgery, known thyroid disease

Oyster Alert: Normal TSH doesn't exclude central hypothyroidism in patients with pituitary disease. Consider free T4 in these patients.

Hyperthyroidism Management

Preoperative Optimization:

Target euthyroid state before elective surgery
Beta-blockade for symptom control and cardiac protection
Antithyroid medications: methimazole preferred over PTU
Consider iodine therapy for rapid control (Lugol's solution)

Perioperative Protocol:

[ ] Continue antithyroid medications until surgery
[ ] Beta-blocker coverage (propranolol 1-2 mg IV q6h or esmolol infusion)
[ ] Stress-dose steroids if severe thyrotoxicosis
[ ] Temperature monitoring and cooling measures
[ ] Avoid precipitants: iodine contrast, amiodarone

Thyroid Storm Management:

Immediate measures:
- Propylthiouracil 600-800 mg loading dose, then 200-400 mg q6h
- Lugol's solution 5 drops q6h (1 hour after PTU)
- Propranolol 1-2 mg IV q5min until HR <100
- Hydrocortisone 200-400 mg q8h
Supportive care:
- Aggressive cooling measures
- Fluid resuscitation and electrolyte correction
- Treat precipitating factors

Clinical Hack: Remember the "PTU before iodine" rule - always give antithyroid drugs before iodine to prevent massive thyroid hormone release.

Hypothyroidism Management

Mild to Moderate Hypothyroidism:

Generally safe to proceed with surgery
Continue levothyroxine therapy
Monitor for delayed drug metabolism

Severe Hypothyroidism (TSH >20 mU/L, low T4):

Consider delaying elective surgery for optimization
Levothyroxine 1.6 μg/kg/day (reduce by 50% in elderly or cardiac disease)
Emergency surgery: can proceed with supportive care

Perioperative Considerations:

[ ] Continue levothyroxine (can crush and give via NGT)
[ ] Expect prolonged drug effects and recovery
[ ] Monitor for hypothermia and cardiovascular instability
[ ] Consider stress-dose steroids if concurrent AI suspected

Pearl: IV levothyroxine dose is 50-75% of oral dose due to improved bioavailability.

Myxedema Coma Management

Recognition:

Severe hypothermia (<95°F)
Altered mental status
Cardiovascular collapse
Hyponatremia, hypoglycemia

Treatment Protocol:

Thyroid hormone replacement:
- T4: 200-400 μg IV loading dose, then 50-100 μg daily
- T3: 10-20 μg IV q8h (if cardiovascular instability)
Supportive measures:
- Passive rewarming (avoid active warming - vasodilation risk)
- Hydrocortisone 100-200 mg IV q8h
- Hypertonic saline for severe hyponatremia
- Mechanical ventilation if needed

4. Steroid Coverage: Evidence-Based Protocols

Physiologic Basis

The normal adrenal response to surgical stress produces 75-150 mg cortisol equivalent daily. Patients with impaired HPA axis function require exogenous steroid supplementation to prevent cardiovascular collapse and other manifestations of relative adrenal insufficiency.

Risk Stratification for Steroid Coverage

High Risk (Stress-dose steroids recommended):

Current steroid use >5 mg prednisone daily
Recent steroid use >20 mg prednisone for >3 weeks within past year
Major surgery with significant physiologic stress
Known primary or secondary adrenal insufficiency

Intermediate Risk (Consider stress-dose steroids):

Low-dose steroids <5 mg prednisone daily for >1 month
Inhaled/topical steroids, especially high-potency or prolonged use
Moderate surgical procedures
History of steroid use with uncertain HPA status

Low Risk (Continue usual dose):

Steroid use <3 weeks duration
Minor surgical procedures
Alternate-day steroid regimens
Recent normal ACTH stimulation test

Steroid Equivalency and Dosing

Steroid Equivalencies (anti-inflammatory potency):

Hydrocortisone: 1x (20 mg)
Prednisone/Prednisolone: 4x (5 mg)
Methylprednisolone: 5x (4 mg)
Dexamethasone: 25x (0.75 mg)

Clinical Hack: Use the "3-2-1 Rule" for steroid surgery dosing:

3 days before major surgery: optimize existing therapy
2x the physiologic dose for moderate stress
1 week to taper back to baseline post-op

Procedure-Specific Protocols

Minor Surgery (local anesthesia, <1 hour):

Continue usual steroid dose
Monitor for signs of insufficiency

Moderate Surgery (regional anesthesia, 1-3 hours):

Hydrocortisone 50 mg IV at induction
Continue usual dose post-operatively
Consider additional 25 mg if prolonged procedure

Major Surgery (general anesthesia, >3 hours, significant stress):

Hydrocortisone 100 mg IV at induction
Hydrocortisone 50 mg IV q8h × 24-48 hours
Taper by 50% daily to maintenance dose

Critical Care Considerations:

Sepsis/septic shock: 200-300 mg hydrocortisone daily
Vasopressor-dependent shock: consider higher doses
ARDS: low-dose protocol (1-2 mg/kg/day methylprednisolone)

Pearl: For patients on chronic steroids, never abruptly discontinue therapy perioperatively - this can precipitate life-threatening adrenal crisis even in minor procedures.

Monitoring and Complications

Parameters to Monitor:

[ ] Blood pressure and hemodynamic stability
[ ] Blood glucose levels
[ ] Electrolytes (sodium, potassium)
[ ] Signs of infection (steroids mask inflammatory response)
[ ] Wound healing
[ ] Mood and behavioral changes

Common Pitfalls:

Inadequate dosing for surgical stress level
Premature tapering of stress-dose steroids
Failure to recognize AI in patients with "borderline" adrenal function
Using anti-inflammatory equivalent rather than glucocorticoid replacement

Special Populations and Considerations

Pediatric Patients

Key Differences:

Higher cortisol production per kg body weight
More rapid onset of AI symptoms
Different steroid dosing: 1-2 mg/kg/day hydrocortisone equivalent

Elderly Patients

Considerations:

Higher prevalence of subclinical endocrine disorders
Increased sensitivity to both hyperglycemia and hypoglycemia
Higher risk of steroid-induced complications
May require lower levothyroxine doses

Emergency Surgery

Rapid Assessment Protocol:

History: Previous steroid use, endocrine disorders, unexplained hypotension
Physical: Signs of AI, thyrotoxicosis, or severe hypothyroidism
Labs: Glucose, electrolytes, consider random cortisol
Management: When in doubt, provide stress-dose steroids

Clinical Hack: In emergency situations, give dexamethasone 4 mg IV instead of hydrocortisone - it doesn't interfere with cortisol assays if you need to check levels later.

Quality Improvement and Implementation

Checklist Implementation Strategies

Pre-implementation:

Multidisciplinary team education
Integration with electronic health records
Clear protocols and decision trees
Regular case reviews and feedback

Key Performance Indicators:

Perioperative glucose control metrics
Incidence of endocrine crises
Length of stay and complication rates
Protocol compliance rates

Common Implementation Barriers

Knowledge gaps: Regular education and updates
Time constraints: Streamlined assessment tools
Communication failures: Clear handoff protocols
Resource limitations: Prioritize high-impact interventions

Future Directions

Emerging Technologies

Continuous glucose monitoring in perioperative settings
Point-of-care cortisol testing
Artificial intelligence-assisted risk prediction
Personalized medicine approaches based on genetic markers

Research Priorities

Optimal glycemic targets for different surgical populations
Novel biomarkers for adrenal insufficiency
Long-term outcomes of perioperative endocrine management
Cost-effectiveness of systematic screening protocols

Conclusion

Systematic attention to perioperative endocrine management through evidence-based checklists can significantly improve patient outcomes and reduce complications. The four key areas - adrenal suppression, diabetes control, thyroid optimization, and steroid coverage - require coordinated, multidisciplinary approaches with clear protocols and regular monitoring.

Implementation of these checklists should be adapted to local resources and patient populations while maintaining adherence to core evidence-based principles. Regular review and quality improvement initiatives ensure optimal outcomes and identify opportunities for protocol refinement.

The complexity of modern surgical patients demands sophisticated understanding of endocrine pathophysiology and its perioperative implications. Through systematic application of these principles, clinicians can optimize surgical outcomes and improve patient safety in the critical perioperative period.

References

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(24):e278-e333.
Bornstein SR, Allolio B, Arlt W, et al. Diagnosis and treatment of primary adrenal insufficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(2):364-389.
American Diabetes Association Professional Practice Committee. 16. Diabetes care in the hospital: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2022;45(Suppl 1):S244-S253.
Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343-1421.
Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association task force on thyroid hormone replacement. Thyroid. 2014;24(12):1670-1751.
Liu MM, Reidy AB, Saatee S, Collard CD. Perioperative steroid management: approaches based on current evidence. Anesthesiology. 2017;127(1):166-172.
Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87(2):663-669.
Griesdale DE, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ. 2009;180(8):821-827.
Polderman JA, Farhang-Razi V, Van Dieren S, et al. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev. 2018;8:CD011940.
Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008;36(6):1937-1949.

Conflicts of Interest: The authors declare no conflicts of interest.

Funding: No funding sources to declare.

Monday, August 25, 2025