Perioperative steroid replacement

Question 1

Which patient’s should/shouldn’t receive additional perioperative steroid coverage

Answer 1

1. Non-suppressed HPA - Continue usual steroids
   - Pred 5 mg daily
   - Pred 10 mg alternate daily
   - Any dose < 3 weeks
2. Suppressed HPA - Give additional perioperative steroids
   - Pred >20mg/day for > 3 weeks
   - Patient’s with cushingoid appearance
3. Indeterminate HPA supression
   - 8am cortisol < 5 - Give additional steroids
   - 8 am cortisol > 10 - No additional steroids
   - 8 am cortisol 5 - 10 - ACTH stimulation test
   - -> ACTH stimulation: 30 min cortisol > 18 - no additional steroids

Question 2

How much additional perioperative steroids should be given in patients determined as having HPA suppression

Answer 2

Mild surgery
- usual morning steroid

Moderate surgery

• Hydrocortisone 50 mg IV just preop
• Hydrocortisone 25 mg8 hrly x 3 doses
• Resume usual steroids thereafter

Major surgery

• Hydrocortisone 100 mg IV just preop
• Hydrocortisone 50 mg IV 8 hrly x 3 doses
• Taper by half per day to maintenance level