What is the recommended stress dose steroid regimen for a patient with a history of chronic steroid use undergoing major surgery?

Stress Dose Steroids for Major Surgery

For patients with chronic steroid use undergoing major surgery, administer 100 mg hydrocortisone IM/IV immediately before anesthesia, followed by 100 mg every 6 hours until the patient can eat and drink, then double their usual oral dose for 48+ hours before tapering to baseline. 1

Critical Patient Distinction

The approach differs dramatically based on why the patient is on chronic steroids:

Patients Requiring Full Stress Dosing

• Primary adrenal insufficiency (Addison's disease) 1, 2
• Secondary adrenal insufficiency from hypothalamic/pituitary disease 2
• Immune checkpoint inhibitor-related adrenal insufficiency 2
• Patients on physiologic replacement doses for documented HPA axis suppression 3

Patients NOT Requiring Supplemental Stress Dosing

• Rheumatic disease patients on ≤16 mg/day prednisone equivalent should continue only their usual daily dose without supplementation 2
• Patients on high-dose chronic steroids for inflammatory conditions can continue their regular regimen without additional stress dosing 2, 3

Common Pitfall: The systematic review evidence shows that patients on therapeutic corticosteroids for inflammatory conditions who continue their usual daily dose do NOT develop adrenal crisis, with 0% incidence in multiple cohort studies 3. Unnecessary stress dosing in these patients increases infection risk without hemodynamic benefit 2.

Major Surgery Protocol (For Patients Requiring Stress Dosing)

Preoperative

• 100 mg hydrocortisone IM/IV immediately before anesthesia induction 1, 2

Intraoperative/Postoperative

• Continue 100 mg hydrocortisone IM/IV every 6 hours until patient tolerates oral intake 1
• Alternative: 200 mg/24 hours as continuous IV infusion 4, 5

Evidence Note: The continuous infusion approach is supported by the most recent pharmacokinetic data (2020) showing it maintains cortisol concentrations in the physiologic stress range more consistently than bolus dosing 5. However, if continuous infusion is unavailable, the every-6-hour bolus regimen remains the guideline-endorsed standard 1, 4.

Transition to Oral

Once able to eat and drink:

• Double the patient's usual oral maintenance dose for 48+ hours 1, 6
• Then taper to normal maintenance dose over 1-2 days 1, 6

Dosing by Surgical Stress Level

High-Stress Procedures (Major Abdominal, Cardiac, Vascular Surgery)

• Hydrocortisone 100 mg IV before anesthesia 2
• Continue 100 mg IV every 6-8 hours for 24-48 hours 2
• Taper over 1-2 days after oral intake established 2

Moderate-Stress Procedures (Joint Replacement, Cholecystectomy)

• Hydrocortisone 50 mg IV before procedure 2
• Resume normal maintenance dose postoperatively 2

Minor Surgery/Major Dental

• 100 mg hydrocortisone IM just before anesthesia 1
• Double oral dose for 24 hours, then return to baseline 1

Emergency Rescue Dosing

If unexplained hypotension occurs intraoperatively despite fluids and vasopressors:

• Administer 100 mg hydrocortisone IV immediately 4
• Follow with 50 mg IV every 6 hours 4
• This applies even if the patient was not identified preoperatively as requiring stress dosing 4

Critical Caveat: Adrenal crisis can occur even when plasma cortisol appears normal (relative adrenal insufficiency), making empiric treatment essential when clinical suspicion exists 4.

Physiologic Rationale

• Normal daily cortisol production: 20 mg/day 4
• Major surgical stress increases requirements up to 5-fold (approximately 100 mg/day) 4, 7
• The 100 mg every 6 hours regimen (400 mg/day total) exceeds physiologic needs but ensures adequate coverage given individual variability 1

Important: Hydrocortisone is the preferred agent because it provides mineralocorticoid activity at high doses, which is critical during stress 4. Dexamethasone lacks mineralocorticoid activity and should only be used as an alternative when hydrocortisone is unavailable 4.

Life-Threatening Pitfalls to Avoid

1. Never delay treatment while awaiting diagnostic confirmation in suspected adrenal crisis 4
2. Never start thyroid hormone or other hormone replacements before corticosteroids in patients with multiple hormone deficiencies—this accelerates cortisol clearance and precipitates crisis 2, 4
3. Failure to identify primary adrenal insufficiency patients leads to preventable adrenal crisis with 6-8 crises per 100 patient-years 1
4. Stopping the patient's usual steroid dose 36-48 hours before surgery increases hypotension risk 3

Patient Safety Essentials

All patients with adrenal insufficiency require:

• Emergency hydrocortisone injection kit (100 mg) for self/family administration 4, 6
• Medical alert bracelet/necklace 4, 6
• Steroid emergency card 2
• Education on stress dosing for sick days 2, 6