Adjust glucocorticoid doses day of surgery per illness severity and stressor magnitude
STEP 1 — Gather Information
Collect patient's current daily hydrocortisone (HC) dose, type and expected duration of surgery, presence of acute illness or comorbidities, baseline adrenal function, and any concurrent medications that affect GC metabolism (e.g., enzyme-inducing AEDs).
STEP 2 — Rule In / Rule Out
Determine if surgical stress is minor/moderate or major. If minor/moderate (e.g., superficial skin procedure, cataract surgery), proceed to Step 3A; if major (e.g., abdominal, thoracic, orthopedic, neurosurgery), proceed to Step 3B.
STEP 3 — Classify or Stratify
3A Minor/Moderate Stress: Suggest 25–75 mg HC per 24 hours (usually given for 1–2 days), adjusted within the range based on illness severity (higher end for sepsis or significant comorbidities).
3B Major Stress: Suggest a 100 mg HC intravenous bolus followed by a continuous intravenous infusion of 200 mg HC per 24 hours (alternatively 50 mg IV every 6 hours).
STEP 4 — Decide
Administer the selected glucocorticoid regimen perioperatively. After 24–48 hours, taper to the patient's usual maintenance dose based on clinical recovery and reassessment of HPA axis function; if stress dosing exceeded 24 hours, consider a gradual taper over an additional day.
Clinical Guardrails / Mimics / Pitfalls
Avoid over-replacement; monitor for hyperglycemia, fluid retention, and cushingoid features. Do not use dexamethasone in pregnancy. Do not abruptly discontinue GCs after stress dosing without a taper. Consider the patient's baseline HC dose when selecting within the 25–75 mg range for minor/moderate stress.
Concrete Clinical Example
A 45‑year‑old woman on HC 15 mg daily for central adrenal insufficiency undergoes elective colectomy (major surgical stress). She receives 100 mg HC IV bolus at induction, then a continuous IV infusion of 200 mg HC over 24 hours. After 24 hours, the infusion is stopped and she resumes her usual 15 mg HC orally in divided doses.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2118