What is the recommended corticosteroid (hydrocortisone) management for a patient with adrenal insufficiency undergoing a right total knee replacement?

Perioperative Corticosteroid Management for Total Knee Replacement in Adrenal Insufficiency

For a patient with adrenal insufficiency undergoing right total knee replacement, hydrocortisone 100 mg IV should be administered at induction, followed by immediate initiation of a continuous infusion of hydrocortisone at 200 mg/24h during surgery and while nil by mouth, then double the regular oral dose for 48 hours after resuming oral intake. 1

Preoperative Management

• Ensure the patient takes their regular morning dose of hydrocortisone (15 mg) on the day of surgery
• Prepare for IV hydrocortisone administration at induction

Intraoperative Management

• Administer hydrocortisone 100 mg IV at induction
• Immediately start continuous IV infusion of hydrocortisone at 200 mg/24h
• Alternative option (if continuous infusion not feasible): hydrocortisone 50 mg IV every 6 hours 1

Postoperative Management

While NPO (Nil Per Os)

• Continue hydrocortisone 200 mg/24h by IV infusion
• Alternative: hydrocortisone 50 mg IV/IM every 6 hours if continuous infusion unavailable 1

Upon Resuming Oral Intake

• Switch to oral hydrocortisone at double the patient's regular dose:
  • Morning: 30 mg
  • Afternoon: 15 mg
  • Evening: 5 mg
  • Total: 50 mg daily (double the usual 25 mg daily dose)
• Continue this doubled dose for 48 hours if recovery is uncomplicated 1, 2
• Return to regular dosing schedule after 48 hours if recovery remains uncomplicated

Monitoring During Hospitalization

• Monitor for signs of inadequate cortisol replacement:
  • Hypotension
  • Tachycardia
  • Nausea/vomiting
  • Confusion
  • Lethargy
  • Fever
• Monitor for signs of excessive cortisol replacement:
  • Hyperglycemia
  • Hypertension
  • Agitation

Important Considerations

• Total knee replacement is considered major surgery and triggers a significant stress response with up to a seventeenfold increase in cortisol production 3
• Patients with adrenal insufficiency cannot mount this necessary stress response and require appropriate supplementation to prevent potentially fatal adrenal crisis 1
• Continuous IV hydrocortisone infusion has been shown to be the most effective method for maintaining appropriate cortisol levels during major stress 4
• If the patient's recovery is complicated or prolonged, consider extending the period of doubled oral dosing for up to one week 1

Common Pitfalls to Avoid

• Underdosing: Inadequate steroid coverage during major surgery can lead to life-threatening adrenal crisis
• Abrupt discontinuation: Always taper back to maintenance dose rather than stopping supplemental steroids suddenly
• Failure to adjust for complications: If the patient develops fever, infection, or other complications, continue the higher steroid doses until the additional stressor resolves
• Overlooking oral medication timing: Ensure the first oral dose is given before the IV infusion is discontinued to avoid gaps in coverage

This approach aligns with the 2020 guidelines from the Association of Anaesthetists, the Royal College of Physicians, and the Society for Endocrinology UK, which provide the most current evidence-based recommendations for perioperative glucocorticoid management in patients with adrenal insufficiency.