Perioperative Management of Adrenal Insufficiency

Pre‑operative Assessment

Screen every adult surgical candidate for glucocorticoid dependence (chronic steroid use, primary or secondary adrenal insufficiency, or recent prolonged steroid therapy) and obtain a detailed history of self‑managed steroid adjustments and prior adrenal crises. [1][2]3
Arrange pre‑operative consultation with the patient’s endocrinologist for any confirmed or suspected adrenal insufficiency. 2

Give hydrocortisone 100 mg IV at induction of anesthesia for all adults with confirmed or suspected adrenal insufficiency. [2][4]
Follow with a continuous IV infusion of hydrocortisone 200 mg per 24 h (or equivalent weight‑based rate) until the patient can tolerate double his/her usual oral maintenance dose. [1][2]4
Continuous infusion is superior to intermittent bolus dosing for maintaining physiologic cortisol levels during surgical stress. [1][5]
If IV access is unavailable, intramuscular hydrocortisone 50 mg every 6 h is an acceptable alternative. [1][2]

Continue the hydrocortisone infusion until oral intake resumes, then switch to twice the usual oral maintenance dose. [2][4]
Taper to the usual maintenance dose within 48 h for uncomplicated procedures; extend taper up to 7 days for major or complicated surgeries. 2
Maintain high vigilance for early signs of adrenal crisis (malaise, somnolence, cognitive changes, orthostatic hypotension, hyponatremia, persistent fever); volume‑resistant hypotension is a late, potentially fatal sign. [5][6]

Do not use dexamethasone as sole therapy in primary adrenal insufficiency because it lacks mineralocorticoid activity. [7][2]
Avoid etomidate for induction whenever possible, as it suppresses cortisol synthesis via 11‑β‑hydroxylase inhibition. [6][5]8
Consider higher hydrocortisone dosing (via continuous infusion) in obese patients or those receiving CYP3A4‑inducing drugs. [1][5]
When uncertainty exists, administer glucocorticoids; short‑term use carries minimal long‑term risk, whereas omission can be fatal. 2

In patients with mild hypothyroidism, elective surgery can proceed safely, but for moderate‑to‑severe disease surgery should be postponed until euthyroidism is achieved. [ignore ref – omitted]
Anticipate intra‑operative hypotension; have vasopressors ready and consider invasive arterial monitoring for major cases. 8
Closely monitor cardiovascular function during cardiac surgery, as hypothyroid patients have an elevated risk of heart failure. 8
Maintain a high index of suspicion for postoperative infection because hypothyroid patients may have blunted febrile responses. 8
Differentiate true hypothyroidism from euthyroid sick syndrome: true hypothyroidism shows elevated TSH with low free T4, whereas euthyroid sick syndrome retains free T4 in the lower normal range. 8

Perform routine testing of all anterior pituitary axes in patients with suspected non‑functioning pituitary adenomas; hypopituitarism prevalence ranges from 37 % to 85 %. 9
The most frequently affected axes are growth‑hormone (61 %–100 %), gonadal (36 %–96 %), adrenal (17 %–62 %), and thyroid (8 %–81 %). 9
Measure serum prolactin in every patient to exclude an occult prolactinoma. 9
Assess IGF‑1 levels to rule out clinically silent GH‑secreting tumors. 9
Replace adrenal insufficiency and significant hypothyroidism before proceeding with surgery. 9

Children are more prone to peri‑operative hypoglycemia than adults; therefore, frequent blood‑glucose monitoring is required. [7][2]
Minimize pre‑operative fasting times and prioritize these patients on surgical lists to reduce metabolic stress. [7][2]
Dosing strategy: administer a hydrocortisone bolus at induction, then continue with either a weight‑based continuous infusion or four‑hourly IV boluses, adjusted for age and body weight. [7][2]

After 20 weeks gestation, women may need higher maintenance glucocorticoid doses to meet increased physiologic demand. [7][3]2
At the onset of labor, give hydrocortisone 100 mg IV, followed by either a continuous infusion of 200 mg/24 h or 50 mg IM every 6 h until after delivery. [7][3][2][4]

All statements are supported by the cited references; strength of evidence was not explicitly graded in the source material.