Perioperative Stress Dose Steroid Protocol Recommendations
For patients with confirmed adrenal insufficiency or those on chronic glucocorticoid therapy (prednisolone ≥5 mg daily for ≥4 weeks), give hydrocortisone 100 mg IV at induction followed immediately by continuous infusion of 200 mg/24 hours until oral intake resumes, then double their usual oral dose for 48 hours (or up to one week for major surgery). 1
Patient Populations Requiring Coverage
Confirmed Adrenal Insufficiency (Primary or Secondary)
- All patients with diagnosed adrenal insufficiency require stress dose coverage regardless of surgery type 1
- This includes patients with Addison's disease, hypopituitarism, or congenital adrenal hyperplasia
Chronic Glucocorticoid Users
- Prednisolone ≥5 mg daily (or equivalent) for ≥4 weeks across ANY route of administration 1
- This includes oral, inhaled, topical, intranasal, and intra-articular routes
- Approximately one-third to one-half of these patients have inadequate adrenal reserve 1
Specific Protocols by Surgery Type
Major Surgery (General or Regional Anesthesia)
Intraoperative:
- Hydrocortisone 100 mg IV at induction
- Immediately start continuous infusion: 200 mg/24 hours 1
- Alternative: Hydrocortisone 50 mg IV/IM every 6 hours 1
Postoperative:
- Continue hydrocortisone 200 mg/24 hours IV infusion while NPO 1
- Once tolerating oral intake: double the usual oral glucocorticoid dose
- Duration: 48 hours for uncomplicated recovery, up to 1 week for major/complicated surgery 1
Intermediate/Body Surface Surgery
For chronic glucocorticoid users:
- Hydrocortisone 100 mg IV at induction
- Continue 200 mg/24 hours infusion 1
- Double regular dose for 48 hours postoperatively if uncomplicated 1
Minor Procedures (Local Anesthesia Only)
For chronic glucocorticoid users on therapeutic doses ≥10 mg prednisolone equivalent:
- Continue usual daily dose only—no additional coverage needed 2
For others on lower doses:
- Consider doubling usual dose for procedure day 2
Special Populations
Obstetric Patients
Labor and Vaginal Delivery:
- Hydrocortisone 100 mg IV at onset of labor
- Continuous infusion 200 mg/24 hours OR 50 mg IM every 6 hours 1
- Continue until after delivery
Cesarean Section:
- Follow major surgery protocol 1
Pediatric Patients
Major Surgery:
- Hydrocortisone 2 mg/kg IV at induction
- Continuous infusion based on weight: 1
- Up to 10 kg: 25 mg/24 hours
- 11-20 kg: 50 mg/24 hours
- Over 20 kg prepubertal: 100 mg/24 hours
- Pubertal: 150 mg/24 hours
- Alternative: 2 mg/kg IV/IM every 4 hours postoperatively
- Critical: Minimize fasting time and prioritize on surgical lists 1
Critical Safety Points
When in Doubt, Treat
If uncertain about the need for glucocorticoids, give them—there are no long-term adverse consequences of short-term administration 1. The risk of adrenal crisis (which carries mortality risk) far outweighs any theoretical harm from brief supplementation.
Common Pitfalls to Avoid
Medication errors on wards: 8.6% of adrenal crisis cases occur due to insufficient perioperative glucocorticoid coverage or medication omissions 1
Dexamethasone in primary adrenal insufficiency: Do NOT use dexamethasone as sole coverage in primary adrenal insufficiency—it lacks mineralocorticoid activity 1
Premature discontinuation: Continue stress dosing if patient remains critically ill, even if plasma cortisol levels appear normal 1
Ignoring patient expertise: Patients with longstanding adrenal insufficiency often recognize early warning signs—listen to their concerns 1
Bowel Preparation Procedures
- Requires clinical supervision with IV fluids and parenteral glucocorticoids during preparation 1
- Especially critical for patients dependent on fludrocortisone or vasopressin 1
Evidence Quality and Nuances
The 2020 UK joint guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology 1 represent the most comprehensive and recent guidance, endorsed by multiple specialty societies. These supersede older recommendations that often suggested higher doses.
Important controversy: For patients on chronic therapeutic glucocorticoids (not diagnosed adrenal insufficiency), evidence is limited. Some systematic reviews 3, 4, 5 suggest continuing usual daily dose may be sufficient. However, the 2020 guidelines recommend full stress dosing 1 given the unpredictability of HPA axis suppression and the serious consequences of adrenal crisis. The 2024 European/Endocrine Society guidelines 2 support this approach for moderate-major stress.
The physiologic basis: Normal cortisol production increases five-fold (to ~100 mg/day) after major surgery, returning to baseline within 24-48 hours 1. The recommended 200 mg/24 hour infusion approximates this stress response.
Risk stratification is unreliable: Biochemical testing (short synacthen test) does not predict who will develop clinical adrenal crisis 3. Approximately 6-8 adrenal crises occur per 100 patient-years in those with known adrenal insufficiency, with documented mortality 1.