What is the intraoperative steroid management for a patient taking prednisone (corticosteroid) 5 mg every 12 hours?

Intraoperative Steroid Management for Patients Taking Prednisone 5 mg Every 12 Hours

For a patient taking prednisone 10 mg daily (5 mg every 12 hours), administer hydrocortisone 100 mg IV at induction followed by a continuous infusion of 200 mg over 24 hours for major surgery, as this dose represents adrenal suppression in a significant proportion of patients. 1

Risk Assessment and Rationale

A daily prednisone dose of ≥5 mg for longer than 1 month represents an adrenal suppressive dose in approximately one-third to one-half of adults, based on short synacthen test data. 1 Although the precise dose-response relationship cannot be demonstrated, this 10 mg daily dose (5 mg BID) clearly falls into the category requiring stress-dose coverage. 1

Given the risks of inadequate glucocorticoid response during surgical stress—including cardiovascular collapse and adrenal crisis—and the lack of long-term harm from short-term supplementation, balanced individualized supplementation is warranted. 1

Intraoperative Protocol by Surgery Type

Major Surgery

• Administer hydrocortisone 100 mg IV bolus at induction 1, 2
• Immediately initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours 1, 2
• Alternative: Dexamethasone 6-8 mg IV at induction provides adequate coverage for 24 hours, though this is less preferred for patients with uncertain adrenal function 1, 3

Intermediate/Body Surface Surgery

• Hydrocortisone 100 mg IV at induction 1, 2
• Follow with continuous infusion of hydrocortisone 200 mg over 24 hours 1, 2

Minor Procedures Without General Anesthesia

• Continue usual oral prednisone dose (5 mg BID) without additional stress-dose coverage 2

Postoperative Management

While NPO or Unable to Tolerate Oral Intake

• Continue hydrocortisone 200 mg/24h by continuous IV infusion 1, 2
• Alternative: Hydrocortisone 50 mg IV or IM every 6 hours 1, 2

Once Tolerating Oral Intake

• Resume oral prednisone at double the pre-surgical dose (10 mg BID = 20 mg daily total) for 48 hours if recovery is uncomplicated 1, 2
• Continue doubled oral dose for up to one week if there are complications or after major surgery 1, 2
• Return to baseline dose (5 mg BID) after the doubled-dose period if recovery is progressing well 1

For Critically Ill Patients

• Continue stress-dose IV hydrocortisone infusion until clinical stability is achieved 3

Conversion Equivalencies

Understanding steroid equivalencies is essential for proper dosing:

• Prednisone 5 mg = Hydrocortisone 20 mg 1
• Prednisone 5 mg = Methylprednisolone 4 mg 1
• Therefore, the patient's baseline prednisone 10 mg daily = hydrocortisone 80 mg daily 1

Evidence Quality and Nuances

The 2020 UK guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology represent the most authoritative and recent guidance on this topic. 1 These guidelines acknowledge that the evidence base is limited—a 2008 systematic review found only two small RCTs and six prospective cohort studies with heterogeneous outcomes. 4

Despite the lack of robust evidence that higher perioperative doses improve hemodynamic or mortality outcomes, the guidelines strongly support supplementation because:

• Adrenal crisis occurs at a rate of 6-8 per 100 patient-years in patients with adrenal insufficiency 3
• Symptoms of adrenal crisis can occur even when plasma cortisol levels appear normal (relative adrenal insufficiency) 1, 3
• Short-term glucocorticoid supplementation has no long-term adverse consequences 3

More recent evidence challenges the necessity of high-dose protocols. A 2014 RCT in IBD patients showed that low-dose steroids (IV hydrocortisone equivalent to presurgical oral dosing) were non-inferior to high-dose steroids (100 mg IV TID) for preventing postural hypotension. 5 A 2020 pharmacokinetic study demonstrated that 25 mg hydrocortisone IV every 6 hours produces cortisol levels that often exceed those in patients without adrenal dysfunction, suggesting current protocols may provide excessive supplementation. 6

However, the most recent 2020 UK guidelines and 2025 Praxis summaries continue to recommend the 100 mg/200 mg protocol as the standard of care, prioritizing safety over theoretical concerns about over-supplementation. 1, 3, 2

Special Considerations

Diabetic Patients

• Expect insulin requirements to increase by 40-60% or more during the perioperative period due to hyperglycemic effects of stress-dose steroids 2
• Monitor blood glucose closely and adjust insulin accordingly 2

IBD Patients

• The British Society of Gastroenterology recommends that IBD patients on corticosteroids at the time of surgery should receive IV hydrocortisone in equivalent dosage until they can resume oral prednisolone 1
• Anaesthetists commonly give a single steroid dose prior to induction (such as dexamethasone 4 mg IV or IM) for those taking more than 5 mg prednisolone 1
• There is no value in increasing steroid dosage beyond the standard protocol to cover stress, as shown in a randomized trial in IBD surgery 1

Critical Pitfalls to Avoid

• Do not withhold stress-dose steroids based solely on preoperative cortisol levels or adrenal function testing, as the surgical stress response requires supplementation even in patients with borderline-normal function 1, 3
• Never abruptly discontinue steroids postoperatively—always taper gradually over 48 hours to one week depending on surgical complexity 1, 2
• Do not use dexamethasone alone in patients with primary adrenal insufficiency, as it lacks mineralocorticoid activity 3, 7
• Avoid inappropriate prolongation of steroids after surgery, particularly in IBD patients who have had complete resection of active disease—standardized taper protocols are beneficial 1
• Do not stop the patient's usual daily corticosteroid dose perioperatively, as this increases the risk of adrenal crisis 4

Algorithm Summary

1. Preoperatively: Continue prednisone 5 mg BID until surgery 4
2. At induction: Hydrocortisone 100 mg IV bolus 1, 2
3. Intraoperatively and first 24h: Hydrocortisone 200 mg/24h continuous IV infusion 1, 2
4. While NPO: Continue hydrocortisone 200 mg/24h IV or 50 mg IV/IM q6h 1, 2
5. Once tolerating PO: Prednisone 10 mg BID (double baseline) for 48h-1 week 1, 2
6. After recovery period: Return to baseline prednisone 5 mg BID 1