Administer stress-dose steroids before surgery and taper after in adrenal insufficiency
STEP 1 — Gather Information
Confirm adrenal insufficiency diagnosis, review current glucocorticoid regimen, determine planned procedure and expected surgical stress (minor/moderate vs major), assess for acute illness or comorbidities. Ends with: Determine surgical stress category.
STEP 2 — Rule In / Rule Out
Is the surgery classified as minor/moderate stress? If yes, proceed to Step 3A; if no (major stress), proceed to Step 3B. Ends with: Branch to appropriate stress-level pathway.
STEP 3 — Classify or Stratify
3A (Minor/Moderate Stress): Select hydrocortisone 25–75 mg per 24 hours in divided doses (e.g., 25 mg PO q8h or 50 mg IV q12h).
3B (Major Stress): Select hydrocortisone 100 mg IV bolus followed by continuous infusion of 200 mg per 24 hours (alternatively 50 mg IV q6h).
Ends with: Choose specific stress-dose glucocorticoid regimen.
STEP 4 — Decide
Administer the selected stress dose perioperatively; after surgery, taper to the patient’s maintenance glucocorticoid dose over 24–48 hours for minor/moderate stress or over 48–72 hours for major stress, then repeat HPA axis testing if clinically indicated. Ends with: Initiate stress-dose glucocorticoids and plan taper.
Clinical Guardrails / Mimics / Pitfalls
Do not use fludrocortisone in secondary AI; avoid dexamethasone in pregnancy; monitor for hyperglycemia, infection, and fluid overload; ensure patient carries an emergency hydrocortisone card/kit; do not taper below maintenance dose before confirming HPA recovery; avoid abrupt discontinuation of steroids.
Concrete Clinical Example
A 45‑year‑old woman with known secondary AI undergoing elective hernia repair (minor stress) receives hydrocortisone 50 mg IV at anesthesia induction, then 25 mg PO q8h for 24 hours, then is tapered to her usual 20 mg AM/10 mg PM over the next day, with an emergency hydrocortisone kit prescribed.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2118