Type of Pre-operative and Post-operative
procedure operative needs (See Note 1) needs (See Note 5)
Lengthy, major surgery 100mg hydrocortisone i/m or Continous i/v infusion 200mg/
with long recovery time i/v just before anaesthesia. 24 hours, alternatively 100mg
eg. open heart surgery, Immediately followed by i/m or i/v every 6 hours
major bowel surgery, continuous i/v infusion until able to eat & drink
procedures needing ITU 200mg/24 hours normally (discharged from ITU).
(See Notes 2, 3) Then double oral dose for
48+ hours. Then taper the
return to normal dose
Major surgery with 100mg hydrocor tisone i/m or Continous i/v infusion 200mg/
rapid recovery i/v just before anaesthesia. 24 hours, alternatively 100mg
eg. caesarean section, Immediately followed by i/m or i/v every 6 hours
joint replacement continuous i/v infusion for 24 - 48 hours (or until
200mg/24 hours eating & drinking normally).
(See Notes 2, 3) Then double oral dose for
24 - 48 hours. Then return
to normal dose
Labour and 100mg hydrocortisone i/m or Double oral dose for
vaginal birth i/v at onset of labour. Then for 24 - 48 hours after
6 hourly until delivery OR deliver y. If well, then return
continuous i/v infusion to normal dose
200mg/24 hours
Minor surgery 100mg hydrocortisone i/m or Double dose oral medication
eg. cataract surgery, hern ia i/v just before anaesthesia. for 24 hours. Then return
repairs, laparoscopy with (See Notes 2, 3) to normal dose
local anaesthetic
Invasive bowel Hospital admission overnight Double dose oral medication
procedures requiring with i/v fluids and 50mg for 24 hours. Then return to
laxatives hydrocortisone i/m during normal dose
eg. colonoscopy, purgative stages of preparation.
barium enema 100mg hydrocortisone i/m
just before commencing.
Other invasive 100mg hydrocortisone i/m Double dose oral medication
procedures just before commencing. for 24 hours. Then return to
eg. endoscopy, gastroscopy normal dose
Minor procedure Not usually required. An extra dose only where
eg. skin mole removal hypoadrenal symptoms
with local anaesthetic occur afterwards
Major dental surgery 100mg hydrocortisone i/m Double dose oral medication
eg. dental extraction just before anaesthesia. for 24 hours. Then return
with general anaesthetic (See Notes 2, 3) to normal dose
Dental surgery Double dose (up to 20mg Double dose oral medication
eg. root canal work hydrocortisone) one hour for 24 hours. Then return
with local anaesthetic prior to surgery. to normal dose
Minor dental procedure Not usually required. An extra dose where
eg. replace filling hypoadrenal symptoms
occur afterwards.
NOTES
1. For any nil-by-mouth regimen, please arrange an intravenous saline infusion to prevent dehydration and maintain
mineralcorticoid stability, eg. 1000ml every 8 hours if >50kg.
2. Intramuscular hydrocortisone is preferable to intravenous administration as it gives more sustained,
stable cover. It may alternatively be given by infusion pump, eg. hydrocortisone 50 - 100mg bolus then
8.33mg per hour or 200 mg/24h
3. Please administer bolus hydrocortisone over a minimum of 10 minutes to prevent vascular damage.
4. Note that hydrocortisone acetate cannot be used due to its slow-release, microcrystalline formulation.
Please use hydrocortisone sodium phosphate or hydrocortisone sodium succinate, 100mg.
5. Monitor electrolytes and blood pressure post-operatively for all procedures requiring injected steroid cover.
If the patient becomes hypotensive, drowsy or peripherally shut down, administer 100mg hydrocortisone i/v or i/m
immediately.
6. If any post-operative complications arise, eg. fever, delay the return to normal dose.
7. Please ensure back-up supplies of oral and injectable hydrocortisone are available for resuscitation before
commencing surgery. Even at full steroid cover, post-operative resuscitation may occasionally be required.
SURGICAL
GUIDELINES
FOR ADDISON’S
DISEASE
AND OTHER
FORMS
OF ADRENAL
INSUFFICIENCY
POTENTIALLY
LIFE-THREATENING
STEROID
DEPENDENCY
STEROIDS
AND SALINE
REQUIREMENTS
FOR SURGERY
AND DENTISTRY
ADDISON’S CLINICAL
ADVISORY PANEL (ACAP)
These surgical guidelines have
been prepared by Professor John
Wass of the Churchill Hospital,
Oxford, Dr Trevor Howlett of
Leicester Royal Infirmary,
Leicester, Professor Wiebke Arlt
of University Hospital, Birmingham
and Professor Simon Pearce of the
Royal Victoria Infirmary, Newcastle.
ACAP is a group of
endocrinologists with an
interest in adrenal medicine.
It advises the Addison’s Disease
Self-Help Group on clinical matters.
Further information about ACAP is
available on the ADSHG website at
www.addisons.org.uk
ACAP has also issued emergency
treatment guidance for hypoadrenalism,
and other patient information leaflets,
available at www.addisons.org.uk.
© ADSHG October 2014
This information may be copied for
personal use or by medical practitioners
for the education of their patients.
Otherwise, it should not be reproduced
without the written permission of the ADSHG.
The Addison’s Disease Self-Help Group
works to support people with adrenal failure
and to promote better medical
understanding of this rare condition.
Registered charity 1106791
www.addisons.org.uk
