Authors: T. Woodcock et al
Anaesthesia Peri-operative medicine, critical care and pain
These guidelines aim to ensure that patients with adrenal insufficiency are identified and adequately supplemented with glucocorticoids during the peri‐operative period. There are two major categories of adrenal insufficiency. Primary adrenal insufficiency is due to diseases of the adrenal gland (failure of the hormone‐producing gland), and secondary adrenal insufficiency is due to deficient adrenocorticotropin hormone secretion by the pituitary gland, or deficient corticotropin‐releasing hormone secretion by the hypothalamus (failure of the regulatory centres). Patients taking physiological replacement doses of corticosteroids for either primary or secondary adrenal insufficiency are at significant risk of adrenal crisis and must be given stress doses of hydrocortisone during the peri‐operative period. Many more patients other than those with adrenal and hypothalamic–pituitary causes of adrenal failure are receiving glucocorticoids as treatment for other medical conditions. Daily doses of prednisolone of 5 mg or greater in adults and 10–15 mg.m−2 hydrocortisone equivalent or greater in children may result in hypothalamo–pituitary–adrenal axis suppression if administered for 1 month or more by oral, inhaled, intranasal, intra‐articular or topical routes; this chronic administration of glucocorticoids is the most common cause of secondary adrenal suppression, sometimes referred to as tertiary adrenal insufficiency. A pragmatic approach to adrenal replacement during major stress is required; considering the evidence available, blanket recommendations would not be appropriate, and it is essential for the clinician to remember that adrenal replacement dosing following surgical stress or illness is in addition to usual steroid treatment. Patients with previously undiagnosed adrenal insufficiency sometimes present for the first time following the stress of surgery. Anaesthetists must be familiar with the symptoms and signs of acute adrenal insufficiency so that inadequate supplementation or undiagnosed adrenal insufficiency can be detected and treated promptly. Delays may prove fatal.
- Prescribed glucocorticoid therapy (prednisolone ≥ 5 mg per day in adults or hydrocortisone‐equivalent dose of 10–15 mg.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.
- All glucocorticoid‐dependent patients are at risk of adrenal crisis as a consequence of surgical stress or illness, and it is essential to be able to recognise and diagnose this medical emergency. If in doubt about the need for glucocorticoids, they should be given as there are no long‐term adverse consequences of short‐term glucocorticoid administration.
- Patients with a long‐standing diagnosis of adrenal insufficiency are often well informed about their disease. Anaesthetists should enquire closely about the patient’s history of glucocorticoid self‐management, any previous episodes of adrenal crisis and how practised they are at medication adjustments for illness, injury or postoperative recovery. Best practice is to collaborate as far as possible with the patient’s endocrinologist when planning scheduled surgery, and when caring for postoperative patients.
- Hydrocortisone 100 mg by intravenous (i.v.) injection should be given at induction of anaesthesia in adult patients with adrenal insufficiency from any cause, followed by a continuous infusion of hydrocortisone at 200 mg.24 h−1, until the patient can take double their usual oral glucocorticoid dose by mouth. This regimen is preferred above others due to enhanced safety. This should then be tapered back to the appropriate maintenance dose, in most cases within 48 h, although for up to a week if surgery is more major/complicated‐clinical judgement should be used to guide this. Intramuscular (i.m.) administration may be prescribed in circumstances where i.v. infusion therapy is impractical (See Tables 1–3 for details).
Table 1. Recommended doses for intra‐ and postoperative steroid cover in adults with primary and secondary adrenal insufficiency Intra‐operative steroid replacement Postoperative steroid replacement Surgery under anaesthesia (general or regional), including joint reduction, endoscopy, IVF egg extraction Hydrocortisone 100 mg intravenously on induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h−1 Hydrocortisone 200 mg.24 h−1 by i.v. infusion while nil by mouth or for patients with postoperative vomiting (alternatively, hydrocortisone 50 mg every 6 h by i.m. injection) Resume enteral – double hydrocortisone doses for 48 h or for up to a week following major surgery.
With rapid recovery
Resume enteral – double hydrocortisone doses for 24 h
Bowel procedures requiring laxatives/enema. Bowel prep under clinical supervision. Consider i.v. fluids and injected glucocorticoid during preparation, especially for fludrocortisone or vasopressin‐dependent patients. Hydrocortisone 100 mg intravenously or intramuscularly at the start of procedure
Resume enteral – double hydrocortisone doses for 24 h Labour and vaginal delivery Hydrocortisone 100 mg intravenously at onset of labour, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h−1 Alternatively, hydrocortisone 100 mg intramuscularly followed by 50 mg every 6 h intramuscularly
Resume enteral – double hydrocortisone doses for 48 h Caesarean section See surgery under anaesthesia - i.m., intramuscular; i.v., intravenous.
Table 2. Recommended doses for intra‐ and postoperative steroid cover in adults receiving adrenosuppresive doses of steroids (prednisolone equivalent ≥ 5 mg for 4 weeks or longer) Intra‐operative steroid replacement Postoperative steroid replacement Major surgery Hydrocortisone 100 mg intravenously at induction, followed by immediate initiation of a continuous infusion of hydrocortisone at 200 mg.24 h−1; Alternatively, dexamethasone 6–8 mg intravenously, if used, will suffice for 24 h
Hydrocortisone 100 mg.24 h−1 by i.v. infusion while nil by mouth (alternatively, hydrocortisone 50 mg every 6 h by i.m. injection) 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 Hydrocortisone 100 mg, intravenously at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h−1 Alternatively, dexamethasone 6–8 mg intravenously, if used, will suffice for 24 h
Double regular glucocorticoid dose for 48 h, then continue usual treatment dose if uncomplicated Bowel procedures requiring laxatives/enema Continue normal glucocorticoid dose. Equivalent i.v. dose if prolonged nil by mouth Treat as per primary adrenal insufficiency if concerned about hypothalamo‐pituitary‐adrenal axis function, and risk of adrenal insufficiency
Labour and vaginal delivery Hydrocortisone 100 mg intravenously at onset of labour, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h−1 Alternatively, hydrocortisone 100 mg intramuscularly followed by 50 mg every 6 h intramuscularly
Caesarean section See major surgery - i.m., intramuscular; i.v., intravenous.
Table 3. Recommended doses for intra‐ and postoperative steroid cover in children with adrenal insufficiency Children Intra‐operative steroid replacement Postoperative steroid replacement Major surgery under anaesthesia (general or regional) Hydrocortisone 2 mg.kg−1 at induction followed by immediate continuous i.v. infusion based on weight: Up to 10 kg; 25 mg.24 h−1
11–20 kg; 50 mg.24 h−1
over 20 kg;
‐ prepubertal 100 mg.24 h−1
‐ pubertal 150 mg.24 h−1
Hydrocortisone 2 mg.kg−1 four hourly intravenously or intramuscularly Or continuous i.v. infusion based on weight:
Up to 10 kg; 25 mg.24 h−1
11–20 kg; 50 mg.24 h−1
over 20 kg;
‐ prepubertal 100 mg.24 h−1
‐ pubertal 150 mg.24 h−1.
Once stable, should receive double usual oral doses of hydrocortisone for 48 h and then reduce to normal doses over up to a week. Add in fludrocortisone if appropriate when enteral feeding established
Minor procedures requiring general anaesthesia Hydrocortisone 2 mg.kg−1 intravenously or intramuscularly at induction of anaesthesia Double normal hydrocortisone doses once enteral feeding established, and continue on double doses for 24 h. Add in fludrocortisone if appropriate when enteral feeding is established Minor procedure NOT requiring general anaesthesia Double morning dose of hydrocortisone given pre‐operatively Normal dose of hydrocortisone - i.v., intravenous.
- Major complications and critical illness excite a prolonged stress response. Any glucocorticoid supplementation should reflect this pattern.
- Dexamethasone is not adequate as glucocorticoid treatment in patients with primary adrenal insufficiency as it has no mineralocorticoid activity.
- Children with adrenal insufficiency are more vulnerable to problems with glycaemic control than adults and require frequent blood glucose monitoring. They can be treated with a bolus of hydrocortisone at induction of anaesthesia followed by an immediate continuous infusion of hydrocortisone, or alternatively with a bolus at induction followed by subsequent four hourly i.v. boluses of hydrocortisone in the postoperative period. Detailed recommendations based on age and body weight are presented in the main text. The period of fasting should be minimised and adrenal insufficient patients should be prioritised on routine surgical operating lists.
- Maternal glucocorticoid supplementation in obstetric patients with adrenal insufficiency represents another group who require special mention; women may require a higher maintenance dose during the later stages of pregnancy (20th week onwards), and stress dose supplementation using hydrocortisone 100 mg at the onset of labour, and then either by continuous i.v. infusion of hydrocortisone 200 mg.24 h−1 or 50 mg intramuscularly every 6 h until after delivery.
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