ESPE Abstracts (2018) 89 P-P2-005

Perioperative Care of CAH - Incongruencies of Practices among Canadian Specialists

Munier Noura, Hardave Gillb, Prosanta Mondalc, Mark Inmana & Kristine Urmsonb

aDivision of Pediatric Endocrinology, Department of Pediatrics, University of Saskatchewan, Saskatoon, Canada; bDepartment of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Canada; cClinical Research Support Unit, College of Medicine, University of Saskatchewan, Saskatoon, Canada

Introduction: In pediatric years, the most common cause of primary adrenal insufficiency is congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. Current Endocrine Society guidelines advocate for the use of perioperative supraphysiologic (often referred to as ‘stress dose’) glucocorticoids for children with primary adrenal insufficiency undergoing general anesthesia or surgery. We perceived a difference in practice patterns amongst pediatric subspecialists which prompted an assessment of perioperative glucocorticoids administration in Canadian centres. To better understand the state of practice patterns of perioperative glucocorticoid administration in children with CAH, we performed a cross sectional survey of Canadian subspecialists.

Methods: Following ethical approval, an electronic survey was sent to Canadian subspecialists using Canadian Pediatric Anesthesia Society (CPAS) and Canadian Pediatric Endocrine Group (CPEG) member email lists (approximately 300 and 85 recipients, respectively) to assess reported practice patterns and responses to select clinical scenarios.

Results: A total of 86 responses were received; 49 anesthesiologists and 37 pediatric endocrinologists. Among anesthesiologists, less than half reported they would provide stress dose steroids for patients undergoing cystoscopy while a clear majority of pediatric endocrinologists reported they would recommend stress dose administration (45% vs 92% respectively, P<0.0001). Over half of endocrinologists (57%) reported to recommend stress dosing regardless of CAH severity or type of procedure being performed. Twenty-one percent of anesthesiologist reported they would not provide stress dose steroids for patients undergoing laparotomy. Pediatric endocrinologists reported they were more likely to refer to guidelines for management of stress dose steroids (84% vs 51%, P<0.001), with many reporting to use institution specific guidelines. Themes emerged in written responses suggesting anesthetists were of the opinion that current guideline recommendations led to overtreatment with glucocorticoids, while endocrinologists believed general-anesthesia itself warrants stress-dose steroids.

Discussion: Current guidelines suggest the use of perioperative supraphysiologic steroids for all patients with primary adrenal insufficiency, with a graded dose depending on degree of surgical stress, in order to pre-emptively prevent clinical deterioration in unforeseen circumstances. Our data has identified a clear difference in self-reported approach to perioperative stress dose steroids between Canadian anesthesiologists and pediatric endocrinologists. It is unclear whether this incongruency is present in other countries or extends to adult practices.

Conclusions: Further dialogue among both pediatric and adult, and endocrine and anesthesia specialists is required to address this apparent discrepancy in practice patterns. Future well-designed research is paramount to provide evidence-based practice recommendations for perioperative management of patients with adrenal insufficiency.

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