Perioperative Management of Cushing's Syndrome

Preoperative Preparation

The American Society of Anesthesiologists recommends controlling cardiovascular and metabolic comorbidities before surgery, including hypertension, diabetes, and electrolyte disorders, in patients with Cushing's syndrome 1, 2
The Endocrine Society suggests considering preoperative medical therapy with steroidogenesis inhibitors in patients with severe hypercortisolism or delayed surgery, although the benefit for all patients is still controversial 1, 2
The American College of Cardiology recommends scheduling patients as the first case to minimize fasting periods and facilitate close postoperative monitoring 1, 2

The American Society of Anesthesiologists recommends administering hydrocortisone 100 mg IV at the time of anesthetic induction, followed by a continuous infusion of 200 mg/24 hours, for all patients with Cushing's syndrome undergoing major surgery 3, 4, 5
The Endocrine Society suggests using dexamethasone 6-8 mg IV as an alternative to hydrocortisone, but notes that it should not be used in primary adrenal insufficiency due to its lack of mineralocorticoid activity 3
The American College of Cardiology recommends monitoring hemodynamics closely due to the risk of volume-resistant hypotension resulting from impaired alpha-adrenergic receptor response to norepinephrine 6, 7

The American Society of Anesthesiologists recommends continuing hydrocortisone infusion at 200 mg/24 hours until the patient can tolerate oral intake, or using an alternative regimen of hydrocortisone 50 mg IV/IM every 6 hours 5, 3, 4, 8
The Endocrine Society suggests monitoring for signs of impending adrenal crisis, including non-specific malaise, somnolence, decreased consciousness, cognitive dysfunction, and orthostatic hypotension 6, 7, 1, 9
The American College of Cardiology recommends checking electrolytes serially, as patients with Cushing's syndrome are at risk of electrolyte disorders 6, 10, 1

The American Society of Anesthesiologists recommends against delaying stress-dose steroid administration based on preoperative cortisol levels alone, as surgical stress requires supplementation even in patients with borderline-normal function 3
The Endocrine Society suggests against using dexamethasone as the primary agent in primary adrenal insufficiency, as it lacks mineralocorticoid activity and has a long half-life that makes dose adjustment difficult 3, 8
The American College of Cardiology recommends against stopping stress-dose steroids abruptly, and instead suggests tapering them gradually over 48 hours to one week, depending on clinical recovery 3, 8

The American Society of Anesthesiologists recommends managing patients with adrenal insufficiency who develop postoperative complications in a critical care setting with intensive monitoring 6, 10, 1
The Endocrine Society suggests continuing stress-dose hydrocortisone infusion until clinical stability is achieved if the patient remains critically ill 3

Metformin should be discontinued 24–48 hours before any major surgery requiring general anesthesia to reduce the risk of peri‑operative lactic acidosis, especially when renal function may be transiently impaired.  11

For patients undergoing adrenalectomy for cortisol‑producing tumors (e.g., Cushing’s syndrome), administer 100 mg hydrocortisone intravenously at induction of anesthesia followed by a continuous infusion of 200 mg over the first 24 hours to prevent life‑threatening adrenal crisis caused by abrupt loss of endogenous cortisol. [12][11]

Patients at risk for postoperative adrenal insufficiency should be provided with a steroid‑emergency identification card and wear a medical‑alert bracelet to ensure rapid recognition and treatment of adrenal crisis. 11