Intraoperative Steroid Management for Patients on Prednisone 10mg Every 12 Hours
For a patient taking prednisone 20mg daily (10mg every 12 hours), administer hydrocortisone 100mg IV at surgical induction, followed immediately by a continuous infusion of hydrocortisone 200mg over 24 hours for major surgery. 1
Understanding the Clinical Context
Your patient is on a supraphysiologic dose of prednisone (20mg daily total), which qualifies as an "adrenosuppressive dose" since it exceeds the threshold of prednisolone equivalent ≥5mg for 4 weeks or longer. 1 This chronic exposure suppresses the hypothalamic-pituitary-adrenal (HPA) axis, preventing the normal physiologic stress response to surgery and creating risk for perioperative adrenal crisis if inadequate corticosteroid coverage is provided.
Intraoperative Protocol by Surgery Type
Major Surgery (Most Common Scenario)
At induction:
Alternative option:
- Dexamethasone 6-8mg IV at induction provides adequate coverage for 24 hours if hydrocortisone infusion is not feasible 1
Body Surface and Intermediate Surgery
- Hydrocortisone 100mg IV at induction 1
- Follow immediately with continuous infusion of hydrocortisone 200mg/24h 1
Minor Procedures NOT Requiring General Anesthesia
- Continue the patient's usual oral prednisone dose (10mg every 12 hours) 1
- No additional stress-dose coverage required for truly minor procedures without general anesthesia 1
Postoperative Management
While NPO or vomiting:
- Continue hydrocortisone 200mg/24h IV infusion 1
- Alternative: hydrocortisone 50mg IV/IM every 6 hours 1
Once tolerating oral intake:
- Resume oral prednisone at double the pre-surgical dose (20mg every 12 hours = 40mg daily total) for 48 hours if recovery is uncomplicated 1
- For major surgery with complications, continue double oral dose for up to one week 1
- Then return to baseline dose of 10mg every 12 hours 1
Critical Pitfalls to Avoid
Never abruptly discontinue steroids perioperatively. 2 The FDA label explicitly warns that abrupt withdrawal can precipitate adrenal insufficiency, which may persist for up to 12 months after discontinuation of chronic therapy. 2
Do not underdose based on older research suggesting continuation of usual dose only. While some studies 3, 4, 5 suggested that patients could safely continue their usual daily dose without stress-dose supplementation, these studies had significant limitations including small sample sizes (37-92 patients) and low-quality evidence. 6 The 2020 UK consensus guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology represent the most authoritative and recent guidance, explicitly recommending stress-dose coverage for all patients on adrenosuppressive doses undergoing major surgery. 1
Monitor for signs of adrenal insufficiency postoperatively: hypotension unresponsive to fluids, unexplained tachycardia, nausea, and hyponatremia. 7, 8 If these occur despite appropriate coverage, immediately administer hydrocortisone 100mg IV bolus and increase infusion rate. 8
Avoid using dexamethasone for long-term postoperative replacement as it lacks mineralocorticoid activity and causes prolonged HPA suppression. 7 Use it only as an intraoperative alternative when hydrocortisone infusion is unavailable.
Special Considerations
For diabetic patients: Expect insulin requirements to increase by 40-60% or more during the perioperative period due to the hyperglycemic effects of stress-dose steroids. 9 The insulin-to-carbohydrate ratio should be reduced by approximately 50% (doubled insulin per gram of carbohydrate) for the first 24 hours after hydrocortisone 100mg administration. 9
Timing matters: The maximal adrenal cortex activity occurs between 2am-8am, so morning surgery is physiologically optimal. 2 However, stress-dose coverage is mandatory regardless of surgical timing for patients on chronic suppressive therapy.
Patient education: Before discharge, ensure the patient understands they must double or triple their maintenance steroid dose during future illness, injury, or stress, as 7% of patients on replacement therapy develop acute adrenal insufficiency during such periods. 7