Administer 25-75 mg hydrocortisone per 24 hours for 1-2 days for minor-moderate surgical stress
STEP 1 — Gather Information
Collect baseline hydrocortisone dose, type and expected duration of surgery, and confirm adrenal insufficiency diagnosis. If patient has adrenal insufficiency and is undergoing minor-moderate surgical stress, proceed to STEP 2; otherwise, use usual maintenance dosing.
STEP 2 — Rule In / Rule Out
Determine if stress dosing is indicated: Yes if adrenal insufficiency present and surgery classified as minor to moderate; No if no adrenal insufficiency or major surgical stress. If yes, proceed to STEP 3; if no, administer usual maintenance glucocorticoid dose.
STEP 3 — Classify or Stratify
Select hydrocortisone dose within 25-75 mg/24h based on surgical stress magnitude: 25 mg for minor stress, 50 mg for moderate stress, 75 mg for higher moderate stress. Divide into 2-3 doses daily (highest dose in morning). Plan duration of 1-2 days, then taper to maintenance.
STEP 4 — Decide
Administer the selected hydrocortisone dose in divided doses for 1-2 days, then reduce to usual maintenance dose while monitoring for signs of over- or under-replacement.
Clinical Guardrails / Mimics / Pitfalls
Avoid exceeding 75 mg/24h to prevent Cushingoid effects; do not use dexamethasone in pregnancy; monitor for hyperglycemia, fluid retention; ensure patient has emergency hydrocortisone kit if adrenal insufficiency is known; do not delay stress dosing in suspected adrenal crisis.
Concrete Clinical Example
A 50-year-old man with secondary adrenal insufficiency undergoing open hernia repair (moderate stress) receives 50 mg hydrocortisone daily (25 mg AM, 25 mg PM) for 2 days, then resumes his usual 20 mg daily dose.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2118