Adrenal insufficiency and stress-dose steroids
Stem
A 61-year-old woman, 68 kg, with rheumatoid arthritis is scheduled for an elective open sigmoid colectomy under general anesthesia. She has taken prednisone 15 mg daily for three years and took this morning's dose. She looks mildly Cushingoid. Blood pressure is 134/80, heart rate 76, sodium 139 and potassium 4.2. There is no history of adrenal crisis.
Question
Does she need perioperative steroid supplementation, and if so, what will you give and when?
Ideal answer
HeadlineYes: her axis may be suppressed, and for major surgery I continue her home dose and give hydrocortisone 100 mg IV at induction.
- At risk above roughly 5 mg prednisone daily for three to four weeks or longer, or with primary adrenal insufficiency or a Cushingoid appearance; shorter courses carry low risk.1
- Parenteral cover under general or regional;1 a minor procedure under local anesthesia would need only the oral dose.
- Then 200 mg over 24 hours while nil by mouth, as an infusion or 50 mg every 6 hours; once eating and stable, double her oral dose for about 48 hours, then the home dose.2
- No etomidate for induction, because one dose suppresses cortisol synthesis for 6–12 hours.
- Hypotension that fluid and vasopressors do not fix gets hydrocortisone 100 mg before I have a cortisol result.3
Watch for: glucose during and after.
Breaking down the answer
- Notice the line in the medication list — the examiner wants it seen before refractory hypotension forces the issue; thresholds for "at risk" have fallen, and the axis recovers slowly and unpredictably.
- Hidden suppressors — high-dose inhaled or topical steroids, intra-articular injection within two months, several formulations at once, or a strong CYP3A4 inhibitor (ritonavir, itraconazole).1 Changes if: unclear history, major surgery: stress dose, not testing; morning cortisol and cosyntropin take time I lack.
- Dose matched to stress — 200 mg per 24 hours approximates the cortisol output of a major operation;2 the older 300 mg regimens were never physiologic and raise glucose, infection and wound risks. Over-supplementing has a cost; that is where judgment is graded.
- Hydrocortisone, not dexamethasone — hydrocortisone has mineralocorticoid activity, which matters in primary disease; above 50 mg daily no separate mineralocorticoid is needed, so fludrocortisone waits until the dose comes down.4 Dexamethasone 6–8 mg IV covers 24 hours when hydrocortisone is unavailable.2
- Etomidate — a single induction dose inhibits 11-beta-hydroxylase for 6–12 hours.5 Avoided in known adrenal insufficiency or septic shock; if I used it and the patient becomes hypotensive, I give hydrocortisone rather than debate the literature.
- Primary versus secondary — primary disease (Addison's, bilateral hemorrhage, adrenalectomy) loses aldosterone too: hyperkalemia, hyponatremia, volume depletion. Secondary, from pituitary failure or exogenous steroids, keeps aldosterone and near-normal electrolytes.3 No fludrocortisone for glucocorticoid-induced insufficiency.1
- Keep steroids going — if she vomits, stays NPO for days or reaches the ICU with sepsis, I convert oral prednisone to intravenous hydrocortisone at an equivalent or stress dose rather than let her miss doses.
Follow-up question
Two hours in, you learn the induction hydrocortisone was never given. Pressure is 70/40 despite 2 L of crystalloid and phenylephrine 200 mcg boluses, heart rate 115, end-tidal CO2 normal.
What do you do?
Follow-up answer
HeadlineVasodilated, vasopressor-resistant shock in a steroid-dependent patient; I tell the surgeon and the room I am treating presumed adrenal crisis.
I clear the differential quickly: bleeding, anaphylaxis, tension pneumothorax, ischemia, anesthetic depth. Hydrocortisone 100 mg IV now, harmless if I am wrong; a cortisol first only if a tube is already in my hand, and I do not wait for it.3 I start norepinephrine and send glucose and potassium, because hypoglycemia and, in primary disease, hyperkalemia accompany crisis; then 200 mg over 24 hours, as an infusion or 50 mg every 6 hours.3 I reassess pressure and vasopressor requirement over 30 minutes. Had I seen the prednisone preoperatively, I would not have cancelled: stress dose, then proceed.
Pitfalls that cost points
- Quoting a full major-surgery regimen for a cataract or a carpal tunnel release under local anesthesia.
- Calling for a third vasopressor before considering cortisol.
- Forgetting that stress-dose hydrocortisone raises glucose in a diabetic.
Rapid-fire
Q: Why not give more than 200 mg of hydrocortisone a day? A: That dose already covers the stress response of major surgery; higher doses only add hyperglycemia and infection risk.
Q: Why does hypotension in adrenal crisis resist catecholamines? A: Cortisol maintains vascular responsiveness to catecholamines by upregulating adrenergic receptors; without it the vessels are deaf to the drug.
Q: When do you taper the stress dose? A: Once eating and stable, double the oral dose for about 48 hours after major surgery, then back to the home dose; no taper is needed for a single perioperative dose.2
Q: Which lab pattern says primary disease? A: Hyponatremia with hyperkalemia and a high ACTH; secondary disease has a low-to-normal ACTH and normal potassium.3
Numbers to know
| Item | Value |
|---|---|
| At-risk threshold | Prednisone-equivalent ≥5 mg/day for ≥4 weeks (ES/ESE: ~4–6 mg for ≥3–4 weeks)2 |
| Minor procedure, local anesthesia | Usual oral dose |
| Intermediate or major surgery | Hydrocortisone 100 mg IV at induction, then 200 mg/24 h (infusion or 50 mg every 6 h)2 |
| After surgery | Double the oral dose for 48 h, then usual dose2 |
| Suspected crisis | Hydrocortisone 100 mg IV, then 200 mg/24 h3 |
| Etomidate suppression | 6–12 h after a single dose5 |
Links
- Intraoperative hypotension: differential and management, Vasopressors and inotropes: choosing and titrating, Sepsis and septic shock, hyperkalemia, Transsphenoidal surgery and acromegaly
- Endocrine Society/ESE guideline on glucocorticoid-induced adrenal insufficiency (2024); Society for Endocrinology and Association of Anaesthetists guidance on perioperative glucocorticoid replacement (2020)
Sources
- 1.Diagnosis and Therapy of Glucocorticoid-Induced Adrenal Insufficiency (clinical practice guideline) · Endocrine Society / European Society of Endocrinology, 2024 · endocrine.orgR2.1 risk thresholds (prednisone ~4–6 mg/day for ≥3–4 weeks); R3.1 parenteral stress dosing for procedures under general or regional anesthesia; R2.12 no fludrocortisone.
- 2.Guidance for the prevention and emergency management of adult patients with adrenal insufficiency (Table 3, peri-operative regimens) · Society for Endocrinology (Clinical Medicine), 2020 · pmc.ncbi.nlm.nih.govApplies to prednisolone-equivalent ≥5 mg for ≥4 weeks; hydrocortisone 100 mg at induction then 200 mg/24 h.
- 3.Adrenal Crisis · StatPearls (NCBI Bookshelf) · ncbi.nlm.nih.gov
- 4.Peri-Operative Glucocorticoid Cover (patient information, based on UHB guideline CG1106) · University Hospitals Birmingham / Society for Endocrinology, 2021 · library.bioscientifica.comNo mineralocorticoid needed while hydrocortisone exceeds 50 mg/24 h.
- 5.Etomidate · StatPearls · statpearls.com
Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.