What is the perioperative management of steroids?

Updated: Jan 09, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD  more...
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A common issue that arises in patients who are on long-term corticosteroid therapy is the perioperative supplementation with stress doses. Several studies have shown that a stress dose is needed only when the hypothalamic-pituitary-adrenal axis (HPAA) is suppressed.

The corticosteroid dose below which HPAA suppression is unlikely is difficult to predict. Many patients take supraphysiologic doses of prednisone (5 mg/d long term, 7.5-10 mg/d for 1 mo, more than 20 mg/d for 1 wk, or high doses of other inhaled corticosteroids) for a variety of conditions and may show evidence of HPAA suppression.

The time to recovery of normal adrenal function after stopping corticosteroids varies from a few days to several months. The best plan is to assume that patients receiving corticosteroids within 3 months of surgery have some degree of HPAA suppression and should receive perioperative supplementation.

When using perioperative corticosteroid supplementation, doses should parallel the physiologic response of the normal adrenal gland to surgical stress, providing only very short-term supplementation. Depending on the dose the patient is taking prior to surgery and the type of operative procedure, the following schedule can be used:

  • In the case of a minor surgery, in a patient on more than 10 mg/d of prednisone (or equivalent), 25-100 mg of hydrocortisone at induction is sufficient. Postoperatively, patients resume the usual dose of corticosteroid the next day.

  • In the case of a major operation, 100 mg of hydrocortisone every 8 hours for 24 hours should be used, on the day of surgery, then the dose of prednisone should be decreased rapidly (ie, 50% per day, down to the usual steroid dose). Oral corticosteroid therapy should be resumed when GI function returns.

  • In the case of ambulatory procedures, administer hydrocortisone (100 mg IV/IM) at discharge, along with a prescription for a rapid taper of prednisone or resumption of the previous steroid dose.

  • A patient taking a high dose of steroids for immunosuppression should be maintained during the perioperative period. For example, for a patient taking 60 mg of prednisone per day, hydrocortisone at 250-300 mg/d parenterally is recommended until the patient can resume the normal oral dose.

  • Remember that when calculating the hydrocortisone dose, prednisone is 4 times stronger.

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