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Adrenal Insufficiency: Rx

Patients taking chronic glucocorticoids are at risk of adrenal crisis during surgery. A daily dose of prednisone of 5mg or more (administered orally topically, inhaled, intranasal, or intra-articular) may result in suppression of the hypothalamic-pituitary axis.Cortisol increases vascular tone andreducedvascular permeability.Whenit is deficient, SVR and myocardial contractibilityare decreased. During extreme stresses such as surgery, this can present as circulatory shock. When manifesting acutely, treatment includes corticosteroids and IV fluids.In patients who take chronic steroids, the anesthesiologist can choose to give a stress dose prior to surgeryto mitigate their increased risk of adrenal crisis.This is meant to both administer the patient’s normal daily dose of steroid, and to supplement the normal adrenal response to surgery. Guidelines differ on the exact amount of steroid to be administered in the stress dose and there are conflicting studies on the risks versus benefits of stress dose steroids. For this reason, the anesthesiologists may individualize their management based on the amount of HPA axis suppression the patient has and the length and type of surgery being performed.


  1. Woodcock T, Barker P, Daniel S, Fletcher S, Wass JAH, Tomlinson JW, Misra U, Dattani M, Arlt W, Vercueil A. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: Guidelines from the Association of Anaesthetists, the Royal College of Physicians and the Society for Endocrinology UK. Anaesthesia. 2020 Feb 3 PubMed Link