Intraoperative Steroid Management for Patients Taking Prednisone

Introduction to Steroid Management

The Association of Anaesthetists recommends administering hydrocortisone 100 mg IV at induction followed by a continuous infusion of 200 mg over 24 hours for major surgery in patients taking prednisone 10 mg daily (5 mg every 12 hours), as this dose represents adrenal suppression in a significant proportion of patients 1, 2
A daily prednisone dose of ≥5 mg for longer than 1 month represents an adrenal suppressive dose in approximately one-third to one-half of adults, based on short synacthen test data 1
The American College of Anaesthetists acknowledges that the evidence base is limited, but strongly supports supplementation because adrenal crisis occurs at a rate of 6-8 per 100 patient-years in patients with adrenal insufficiency, and short-term glucocorticoid supplementation has no long-term adverse consequences 1

For major surgery, administer hydrocortisone 100 mg IV bolus at induction, followed by a continuous IV infusion of hydrocortisone 200 mg over 24 hours 1, 2
Alternative: Dexamethasone 6-8 mg IV at induction provides adequate coverage for 24 hours, though this is less preferred for patients with uncertain adrenal function 2

While NPO or unable to tolerate oral intake, continue hydrocortisone 200 mg/24h by continuous IV infusion 1, 2
Once tolerating oral intake, resume oral prednisone at double the pre-surgical dose (10 mg BID = 20 mg daily total) for 48 hours if recovery is uncomplicated 1, 2
Continue doubled oral dose for up to one week if there are complications or after major surgery 1, 2

The British Society of Gastroenterology recommends that IBD patients on corticosteroids at the time of surgery should receive IV hydrocortisone in equivalent dosage until they can resume oral prednisolone 3
There is no value in increasing steroid dosage beyond the standard protocol to cover stress, as shown in a randomized trial in IBD surgery 3

Prednisone 5 mg = Hydrocortisone 20 mg 3
Prednisone 5 mg = Methylprednisolone 4 mg 3
Therefore, the patient's baseline prednisone 10 mg daily = hydrocortisone 80 mg daily 3

For patients taking prednisone 20mg daily, the American Association of Anaesthetists recommends administering hydrocortisone 100mg IV at surgical induction, followed by a continuous infusion of hydrocortisone 200mg over 24 hours for major surgery 4, 5, 6

The Association of Anaesthetists guidelines suggest that for major surgery, hydrocortisone 100mg IV bolus should be administered at induction, followed immediately by a continuous infusion of hydrocortisone 200mg/24h 4, 5, 6
For body surface and intermediate surgery, the Royal College of Physicians recommends hydrocortisone 100mg IV at induction, followed by a continuous infusion of hydrocortisone 200mg/24h 4, 5, 6
The Society for Endocrinology guidelines state that for minor procedures not requiring general anesthesia, patients should continue their usual oral prednisone dose, with no additional stress-dose coverage required 4, 5, 6

The UK consensus guidelines recommend continuing hydrocortisone 200mg/24h IV infusion while the patient is NPO or vomiting, with an alternative option of hydrocortisone 50mg IV/IM every 6 hours 4, 5, 6
Once the patient is tolerating oral intake, the guidelines suggest resuming oral prednisone at double the pre-surgical dose for 48 hours if recovery is uncomplicated, and for up to one week if there are complications 4, 5, 6

The Association of Anaesthetists guidelines warn that diabetic patients may experience an increase in insulin requirements by 40-60% or more during the perioperative period due to the hyperglycemic effects of stress-dose steroids 7
The Society for Endocrinology recommends that patients on chronic corticosteroid therapy should be educated on the importance of doubling or tripling their maintenance steroid dose during future illness, injury, or stress to prevent acute adrenal insufficiency 8