What is the stress dosing order for hydrocortisone (cortisol replacement) for a patient on 5mg of prednisone (corticosteroid) undergoing surgery?

Hydrocortisone Stress Dosing for Surgery in Patient on 5 mg Prednisone

For a patient on 5 mg of prednisone undergoing surgery, hydrocortisone stress dosing should include 100 mg intravenously at induction, followed by immediate initiation of a continuous infusion of hydrocortisone at 200 mg/24 hours. 1

Rationale for Stress Dosing

A daily glucocorticoid dose equivalent to prednisolone ≥5 mg for longer than 1 month represents an adrenal suppressive dose in a significant proportion of adults. Studies show approximately one-third to half of patients on this dose may not achieve adequate cortisol response when tested 1. This puts the patient at risk for relative adrenal insufficiency during the stress of surgery.

Stress Dosing Protocol Based on Surgery Type

Major Surgery

• Pre-operative: No specific additional pre-operative dose required

• Intra-operative:

  • Hydrocortisone 100 mg IV at induction
  • Immediately followed by continuous infusion of hydrocortisone 200 mg/24 hours 1
  • Alternative: If dexamethasone 6-8 mg IV is used (e.g., for antiemetic purposes), this will suffice for 24 hours

• Post-operative:

  • Continue hydrocortisone 200 mg/24 hours by IV infusion while NPO 1
  • Alternative: Hydrocortisone 50 mg every 6 hours by IM injection if IV infusion not feasible
  • Once oral intake resumes: Double the pre-surgical therapeutic dose (10 mg prednisone daily) for 48 hours if recovery is uncomplicated
  • For complicated recovery: Continue double oral dose for up to a week 1

Intermediate/Body Surface Surgery

• Intra-operative: Same as major surgery
• Post-operative: Double regular glucocorticoid dose for 48 hours, then resume usual treatment dose if uncomplicated 1

Administration Methods

Continuous IV infusion is superior to intermittent bolus dosing for maintaining plasma cortisol concentrations that mimic a normal stress response 1, 2. A pharmacokinetic study showed that continuous IV hydrocortisone infusion was the only administration mode consistently achieving median cortisol concentrations in the range observed during major stress 2.

If IV infusion is not practical, intermittent dosing can be used:

• Hydrocortisone 50 mg IV/IM every 6 hours 1, 3

Important Considerations and Pitfalls

1. Never omit stress dosing: Adrenal crisis is a life-threatening complication with significant mortality risk. If in doubt about the need for glucocorticoids, they should be given, as there are no long-term adverse consequences of short-term glucocorticoid administration 1.

2. Medication errors: A British survey found that 8.6% of patients with adrenal insufficiency reported a previous adrenal crisis caused by insufficient glucocorticoid medication during an inpatient stay 1. Ensure proper documentation and communication with all staff.

3. Duration of therapy: In general, high-dose corticosteroid therapy should be continued only until the patient's condition has stabilized, usually not beyond 48 to 72 hours 3.

4. Special populations: Consider higher doses in patients taking drugs that induce CYP3A4 and in obese adults, as these factors may affect hydrocortisone metabolism 1.

5. Monitoring: Maintain a high index of suspicion for adrenal crisis. Signs include progressive hypotension, nausea, vomiting, abdominal pain, lethargy, and fever.

By following these evidence-based guidelines for perioperative glucocorticoid management, the risk of adrenal crisis can be minimized while avoiding unnecessary prolonged high-dose steroid exposure.