Administer 100-mg hydrocortisone IV bolus followed by continuous infusion for major surgical stress
STEP 1 — Gather Information
Confirm diagnosis of central adrenal insufficiency (AI) or high suspicion, verify patient is undergoing major surgical stress, review current glucocorticoid regimen, assess for signs of adrenal crisis, and check fluid status and glucose; if AI confirmed/suspected and major surgical stress present, proceed to Step 2.
STEP 2 — Rule In / Rule Out
Is the patient diagnosed with central AI or has high suspicion of AI? If yes, proceed to Step 3; if no, consider standard perioperative glucocorticoid dosing or hold stress dose and reassess.
STEP 3 — Classify or Stratify
Classify stress level as major surgical stress (e.g., bowel resection, cardiac surgery, major orthopedic procedure) versus minor/moderate stress; if major, continue to dosing decision.
STEP 4 — Decide
Administer 100 mg hydrocortisone IV bolus, then start continuous IV infusion of 200 mg HC per 24 hours (or 50 mg IV every 6 hours) and monitor response.
Clinical Guardrails / Mimics / Pitfalls
Avoid excessive dosing that may cause hyperglycemia, fluid overload, or infection; do not use dexamethasone in pregnancy; taper glucocorticoids postoperatively once HPA axis recovers; monitor for signs of adrenal insufficiency despite stress dosing; consider renal function when adjusting infusion rate; ensure patient has emergency glucocorticoid kit.
Concrete Clinical Example
A 48-year-old man with known central AI undergoing open abdominal aortic aneurysm repair receives 100 mg HC IV bolus in the operating room, followed by a continuous infusion of 200 mg HC over 24 hours (≈8.3 mg/h); postoperative course uncomplicated.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, https://doi.org/10.1210/jc.2016-2118
TODO: consider adding scripts/calc.py for the ata-major-stress-hc-regimen calculator