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Steroid Management

Steroid Cover for Chronic Steroid Related Adrenal Insufficiency

Steroid Cover for Chronic Steroid Related Adrenal Insufficiency1

Prescribed glucocorticoid therapy (prednisolone ≥ 5 mg.day-1 in adults or hydrocortisone-equivalent dose of 10–15mg.m-2 per day in children) across all routes of administration (oral, inhaled, topical, intranasal, intra-articular), can cause suppression of the hypothalamo–pituitary–adrenal axis, and is the most common cause of adrenal insufficiency that anaesthetists will encounter.

Glucorticoid-dependent patients are at risk of adrenal crisis as a consequence of surgical stress or illness, and should be given supplementary steroids as per the following table.

Intraoperative

Postoperative

Major Surgery inc LUSCS

IV Hydrocortisone 100mg at Induction.

Then immediate infusion at 200mg.24hrs-1

Alternatively Dexamethasone 6-8mg IV will suffice for 24 hours

Hydrocortisone 100 mg.24hrs-1 by IV infusion while NBM

Alternatively, hydrocortisone 50 mg IM q6h

Resume enteral glucocorticoid at pre-surgical therapeutic dose if recovery is uncomplicated.

Otherwise continue double oral dose for up to a week

Body Surface and Intermediate Surgery

Double regular glucocorticoid dose for 48hr

Then continue usual treatment dose if uncomplicated

Bowel Prep

Continue usual Glucocorticoid Dose. Convert to IV if NBM.

Treat as per primary adrenal insufficiency if concerned about axis function and risk of adrenal insufficiency

Labour and Vaginal Delivery

IV Hydrocortisone 100mg at Onset of Labour.

Then immediate infusion of 200mg/day.

Alternatively, Hydrocortisone 100mg IM followed by 50mg IM q6h

Major Surgery inc LUSCS

Intraoperative

IV Hydrocortisone 100mg at Induction.

Then immediate infusion at 200mg.24hrs-1

Alternatively Dexamethasone 6-8mg IV will suffice for 24 hours

Postoperative

Hydrocortisone 100 mg.24hrs-1 by IV infusion while NBM

Alternatively, hydrocortisone 50 mg IM q6h

Resume enteral glucocorticoid at pre-surgical therapeutic dose if recovery is uncomplicated.

Otherwise continue double oral dose for up to a week

Body Surface and Intermediate Surgery

Intraoperative

IV Hydrocortisone 100mg at Induction.

Then immediate infusion at 200mg.24hrs-1

Alternatively Dexamethasone 6-8mg IV will suffice for 24 hours

Postoperative

Double regular glucocorticoid dose for 48hr

Then continue usual treatment dose if uncomplicated

Bowel Prep

Intraoperative

Continue usual Glucocorticoid Dose. Convert to IV if NBM.

Treat as per primary adrenal insufficiency if concerned about axis function and risk of adrenal insufficiency

Postoperative

Labour and Vaginal Delivery

Intraoperative

IV Hydrocortisone 100mg at Onset of Labour.

Then immediate infusion of 200mg/day.

Alternatively, Hydrocortisone 100mg IM followed by 50mg IM q6h

Postoperative

References

  1. Guidelines for the management of glucocorticoids during the perioperative period for patients with adrenal insufficiency - Anaesthesia 2020
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