Management of Suspected Adrenal Insufficiency During Surgery

Recognition and Management

For patients with suspected adrenal insufficiency during surgery, immediately administer hydrocortisone 100 mg intravenously followed by continuous infusion of hydrocortisone at 200 mg/24 hours to prevent adrenal crisis and reduce mortality, as recommended by the Association of Anaesthetists 1, 2
The American College of Anaesthetists recommends administering hydrocortisone 100 mg IV bolus immediately, followed by continuous IV infusion of hydrocortisone 200 mg/24 hours, for adults with suspected adrenal insufficiency during surgery 1, 2
For children with suspected adrenal insufficiency during surgery, administer hydrocortisone 2 mg/kg IV/IM immediately, followed by continuous IV infusion based on weight, as recommended by the Society for Endocrinology UK 2, 4

Continue IV hydrocortisone while the patient is nil by mouth, and transition to oral glucocorticoids at double the usual maintenance dose for 48 hours once the enteral route is available, as recommended by the Royal College of Physicians 1, 2, 5
For patients on chronic steroids, stress-dose coverage is required according to the same protocol as those with known adrenal insufficiency, as recommended by the Association of Anaesthetists 5, 4

Patients receiving prednisolone equivalent ≥5 mg for 4 weeks or longer require stress-dose coverage according to the same protocol as those with known adrenal insufficiency, as recommended by the Society for Endocrinology UK 5, 4
For patients with primary adrenal insufficiency, add fludrocortisone once enteral feeding is established, as recommended by the Royal College of Physicians 2, 4
Dexamethasone 6-8 mg IV may be used instead of hydrocortisone for major surgery and will provide coverage for 24 hours, as recommended by the Association of Anaesthetists 2, 5