What are the guidelines for perioperative corticosteroid (steroid) use in patients undergoing surgery, based on surgery risk and individual patient risk factors, including those with pre-existing conditions such as adrenal insufficiency?

Perioperative Corticosteroid Management by Surgery Risk

For patients with adrenal insufficiency or on chronic corticosteroid therapy (≥5 mg prednisone equivalent for ≥4 weeks), administer hydrocortisone 100 mg IV at induction followed immediately by continuous infusion of 200 mg over 24 hours for major surgery, regardless of the specific surgical procedure. 1

Patient Risk Stratification

Patients Requiring Stress-Dose Coverage

Definite adrenal suppression (require full stress-dose protocol):

• Primary or secondary adrenal insufficiency (any dose, any duration) 1
• Chronic corticosteroid therapy ≥20 mg prednisone daily (or equivalent) 2
• Prednisone ≥5 mg daily for ≥4 weeks (represents adrenal suppression in one-third to one-half of patients) 1, 3

Uncertain adrenal function (5-20 mg prednisone daily):

• Consider HPA axis testing preoperatively, though the Association of Anaesthetists notes these tests are overly sensitive and do not predict who will develop adrenal crisis 4
• In clinical practice, treat as adrenal suppression given the low risk of short-term hydrocortisone supplementation 1

No supplementation required:

• Patients on <5 mg prednisone daily do not require additional perioperative coverage beyond their usual dose 2
• Minor procedures without general anesthesia in patients on chronic steroids—continue usual oral dose only 3

Intraoperative Protocol by Surgery Type

Major Surgery (Open Procedures, General Anesthesia)

Standard protocol for all major surgery:

• Hydrocortisone 100 mg IV bolus at induction 1, 5
• Immediately initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours (approximately 8.3 mg/hour) 1, 5
• Alternative: Hydrocortisone 50 mg IV or IM every 6 hours (less preferred than continuous infusion) 1, 6

This protocol applies to:

• Abdominal surgery, thoracic surgery, major orthopedic procedures 1
• Cesarean section 1, 5
• Any surgery under general or regional anesthesia 1

Intermediate/Body Surface Surgery

Same protocol as major surgery:

• Hydrocortisone 100 mg IV at induction, followed by 200 mg/24h continuous infusion 3
• The Association of Anaesthetists guidelines do not distinguish between major and intermediate surgery for dosing purposes 1

Minor Procedures

For procedures not requiring general anesthesia:

• Continue usual oral corticosteroid dose without additional stress coverage 3
• Examples include joint reduction, endoscopy, IVF egg extraction under local/conscious sedation 1

Special Procedures

Labor and vaginal delivery:

• Hydrocortisone 100 mg IV at onset of labor, followed by continuous infusion 200 mg/24h 1
• Alternative: Hydrocortisone 100 mg IM, then 50 mg IM every 6 hours 1, 6

Bowel preparation procedures:

• Hydrocortisone 100 mg IV or IM at start of procedure 1
• Bowel prep should be under clinical supervision with consideration of IV fluids and injected glucocorticoid during preparation, especially for fludrocortisone-dependent patients 1

Postoperative Management

While NPO or Vomiting

Continue stress-dose coverage:

• Hydrocortisone 200 mg/24h by continuous IV infusion 1, 5
• Alternative: Hydrocortisone 50 mg IV or IM every 6 hours 1

Once Tolerating Oral Intake

Uncomplicated recovery:

• Resume oral glucocorticoid at double the pre-surgical dose for 48 hours 1, 5
• Then return to baseline maintenance dose 1

Complicated recovery or major surgery:

• Continue double oral dose for up to one week 1, 5
• Gradually taper to maintenance dose over this period 1

Rapid recovery (minor procedures):

• Resume oral glucocorticoid at double dose for 24 hours only 1

Critical Pitfalls to Avoid

Medication Selection Errors

• Never use dexamethasone as the primary agent for patients with adrenal insufficiency—it lacks mineralocorticoid activity and has a prolonged half-life that makes dose adjustment difficult 5, 6
• Never delay steroid administration for diagnostic testing in patients with known or suspected adrenal insufficiency—treat immediately 5
• Ensure patients with primary adrenal insufficiency receive fludrocortisone once oral intake resumes, as they require mineralocorticoid replacement in addition to glucocorticoid coverage 5

Dosing and Timing Errors

• Do not abruptly discontinue stress-dose steroids—always taper gradually to maintenance doses over 48 hours to one week depending on recovery 5, 3
• Do not stop usual daily corticosteroid dose in patients on chronic therapy—continue baseline dose throughout perioperative period 4
• Do not reduce steroid supplementation while patient is pyrexial—persistent fever may be due to adrenal insufficiency, not just infection 1

Monitoring Failures

• Monitor for early signs of adrenal crisis before hypotension develops: non-specific malaise, somnolence, cognitive dysfunction, orthostatic hypotension 1
• Check sitting and supine blood pressure for early detection of orthostatic hypotension 1
• Recognize that plasma sodium may be low but is not always present in adrenal insufficiency 1

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 3
• This is a manageable side-effect and should not prevent appropriate steroid coverage 1

Patients on Chronic Steroids Without Known Adrenal Insufficiency

Controversial evidence exists:

• Two RCTs (37 patients total) and five cohort studies (462 patients) showed no significant difference in outcomes between stress-dose supplementation versus usual dose continuation 7, 4
• However, the Association of Anaesthetists strongly supports supplementation because adrenal crisis occurs at 6-8 per 100 patient-years in adrenal insufficiency, and short-term glucocorticoid supplementation has no long-term adverse consequences 3
• In clinical practice, err on the side of supplementation given the low risk and potentially catastrophic consequences of adrenal crisis 1, 3

Patient Education and Engagement

• Listen to well-informed adrenal patients who state they need additional steroids—they may be more knowledgeable than their anesthetist 1
• Patients may carry steroid emergency cards, medical bracelets, or self-administration kits 1
• Verify patient education on "Sick Day Rules" (doubling dose during stress), as some patients are discharged with inadequate education 1

Physiologic Rationale

• Normal cortisol production is approximately 20 mg daily 1
• Major surgery induces a five-fold increase to approximately 100 mg daily 1, 8
• Plasma cortisol typically returns to baseline within 24-48 hours after uncomplicated surgery 1
• The 200 mg/24h infusion mimics this physiologic stress response 1, 8