Steroids — Perioperative Management
The perioperative plan should answer three different questions: does this patient need adrenal replacement or stress coverage, is an antiemetic steroid appropriate, and how does chronic exposure affect healing? A single dexamethasone dose and long-term prednisone therapy have different evidence and risks. This workflow uses the 2024 ESE/Endocrine Society guideline for glucocorticoid-induced adrenal insufficiency.[1]
See also: Corticosteroid pharmacology, Immunosuppression, Nausea & Vomiting, and Wound Healing.
Identify Adrenal-Insufficiency Risk
Record the drug, route, current and previous doses, duration, recent taper, last dose, prior adrenal testing/crisis and interacting medication. Oral exposure expected to pose risk generally exceeds both 3–4 weeks and a physiologic daily equivalent: approximately hydrocortisone 15–25 mg or prednisone/prednisolone 4–6 mg. These ranges are guides, not absolute safe/unsafe boundaries.[1]
- Known adrenal insufficiency and exogenous Cushingoid features require an explicit coverage plan.
- A current prednisone dose below 5 mg does not prove recovery after a higher-dose course or taper.
- A genuinely short course under 3–4 weeks usually does not require tapering or routine HPA testing, but consider repeated exposure and the clinical context.
- Inhaled, topical, injected and other non-oral steroids can suppress the axis. Higher potency/dose, prolonged use, simultaneous formulations, recent intra-articular injections and strong CYP3A4 inhibitors increase concern. No single inhaled-dose cutoff clears every preparation or patient.[1]
For patients with current/recent exposure in whom glucocorticoid-induced adrenal insufficiency has not been excluded, the guideline recommends stress coverage during relevant stress. The route and dose depend on severity, absorption and the baseline regimen. This is not an instruction to give every person using any steroid a major-surgery infusion.[1]
Testing for Recovery
When long-term treatment is no longer needed and the patient has reached a physiologic dose, a morning cortisol is the guideline's first test for HPA recovery if testing is chosen. Obtain it at 8–9 AM after an appropriate medication hold—usually at least 24 hours; dexamethasone requires separate consideration. Arrange this with the prescribing team rather than withholding necessary treatment around surgery.[1]
| Morning cortisol in this recovery-testing context | Guideline interpretation |
|---|---|
| Above 10 μg/dL (approximately 300 nmol/L) | Recovery is likely; stopping replacement can be considered when the underlying indication permits. |
| 5–10 μg/dL | Continue physiologic replacement and repeat after weeks to months. |
| Below 5 μg/dL (approximately 150 nmol/L) | Continue replacement and repeat after a few months. |
Interpret values as a continuum, using the assay and clinical setting. Estrogen, low binding proteins, critical illness and sleep disruption affect total cortisol. These are recovery thresholds, not universal diagnostic cutoffs for every adrenal disorder. Routine dynamic testing is discouraged during taper; when necessary, the standard 250-microgram ACTH test and assay-specific interpretation are preferred over routinely using the 1-microgram test.[1]
Preserve Required Treatment Without Duplicating Doses
Avoid an unplanned interruption of necessary glucocorticoid therapy. If oral treatment cannot be taken or absorbed, prescribe an appropriate parenteral regimen. Count the glucocorticoid exposure supplied by that regimen: do not automatically add the full oral dose again to an IV dose that already replaces it and provides stress coverage. Document the return to the usual treatment, particularly in transplant recipients or active inflammatory disease.[1][2]
Stress Coverage
The following is a summary of ESE/Endocrine Society Table 8 for adults at risk of or with diagnosed glucocorticoid-induced adrenal insufficiency. These suggested schedules are based substantially on clinical practice; head-to-head evidence is limited and some centers use lower-dose regimens. Agree the plan with anesthesia/endocrinology when risk or recovery is uncertain.[1]
Minor Stress or a Procedure Under Local Anesthesia
If the patient already takes hydrocortisone at least 40 mg/day, prednisone at least 10 mg/day or dexamethasone at least 1 mg/day, an increase is usually unnecessary for minor stress when stable and absorbing medication.
For a local-anesthetic procedure in someone needing coverage at a lower dose, the table gives oral hydrocortisone 40 mg total: 20 mg one hour before, then 10 mg six hours later and another 10 mg after a further six hours. Prednisone 10 mg or dexamethasone 1 mg one hour before are alternative schedules for patients using those drugs at lower doses. Continue increased coverage if still unwell; do not lower a higher baseline dose to these examples.[1]
The actual anesthetic/stress matters: cystoscopy or stent work performed under general anesthesia does not automatically follow the office/local schedule.
General or Regional Anesthesia
Table 8 suggests hydrocortisone 100 mg IV at induction, followed immediately by 200 mg over 24 hours, or 50 mg IV every six hours if infusion is unavailable. For prolonged NPO/long recovery, maintain parenteral coverage and reassess daily. Once recovery is uncomplicated and oral absorption is reliable, use increased oral coverage for 48 hours—examples are hydrocortisone 40 mg/day, prednisone 10 mg/day or dexamethasone 1 mg/day—then return to the required preoperative regimen. Preserve a higher baseline dose; infection, reoperation or ongoing illness requires reassessment.[1]
A patient already receiving hydrocortisone at least 200 mg/day, prednisone at least 50 mg/day or dexamethasone approximately 6–8 mg/day usually does not need additional glucocorticoid for moderate/major stress, but the route must remain reliable. These thresholds do not eliminate the need to evaluate deterioration or missed absorption.[1]
For labor/delivery or primary adrenal insufficiency with mineralocorticoid requirements, use the relevant obstetric/endocrine plan rather than a generic urologic procedure table.
Suspected Adrenal Crisis
Consider crisis with hypotension, collapse, severe weakness, vomiting/diarrhea, abdominal symptoms, hypoglycemia or unexplained deterioration in a patient with known or possible adrenal insufficiency. Do not wait for fluid-resistant shock or laboratory confirmation. Treat competing causes such as hemorrhage and sepsis simultaneously.[1][2]
- Give hydrocortisone 100 mg IV or IM immediately.
- Start prompt isotonic fluid resuscitation, individualized to perfusion, cardiac/renal status and ongoing losses. NICE specifies 1 L of 0.9% saline over 30 minutes in adults with crisis; reassess closely for overload.
- Continue hydrocortisone 200 mg/24 hours by infusion, or 50 mg IV/IM every six hours.
- Monitor blood pressure, heart rate, electrolytes and glucose; treat hypoglycemia and the precipitating illness.
- Obtain cortisol/ACTH before treatment if immediately feasible, but never delay hydrocortisone or resuscitation. Arrange endocrine guidance for taper and oral transition.[1][2][3]
Hyperkalemia particularly suggests mineralocorticoid-deficient primary adrenal disease or another cause; aldosterone is usually preserved in glucocorticoid-induced insufficiency, for which routine fludrocortisone is not indicated.[1]
After stabilization, provide a clear sick-day plan, an emergency steroid card/medical alert and access to an emergency hydrocortisone injection kit with training when indicated. Do not assume a universally available autoinjector.[2][3]
Dexamethasone for PONV
Use the PONV workflow and corticosteroid hub for antiemetic selection and doses. Coordinate this with stress coverage; hydrocortisone replacement has not been established as an equivalent antiemetic regimen. A non-steroid antiemetic may avoid unnecessary duplicate glucocorticoid exposure.
PADDI randomized 8,880 adults undergoing nonurgent noncardiac surgery to a single 8-mg IV dexamethasone dose or placebo. Among 8,678 in the primary analysis, 30-day SSI occurred in 8.1% versus 9.1%, meeting noninferiority; 24-hour PONV was lower. This supports the studied single dose, not prolonged glucocorticoid exposure or a guarantee of unaffected graft/anastomotic healing. Patients with primary infection and HbA1c above 9% were excluded. Transient hyperglycemia remains relevant, including in patients without diabetes.[4]
Chronic Exposure and Reconstruction
Chronic glucocorticoids can impair healing and increase infection risk, with effects varying by dose, duration, disease and operation. A broad surgical review cannot establish a universal prednisone cutoff for buccal-graft failure, urethral restricture or AUS/IPP infection.[5]
Before elective reconstruction, coordinate any taper to the lowest dose that safely controls the underlying disease; do not taper solely for surgery when this would destabilize disease or threaten an allograft. Optimize nutrition, glucose and other modifiable risks, and assess fracture risk under the relevant glucocorticoid-osteoporosis pathway.
Operation-specific guidance should remain scoped. ECCO's 2026 UC surgical guideline recommends tapering corticosteroids below 20 mg prednisolone-equivalent before elective proctectomy/restorative surgery, based on low-level evidence. That is not a validated 10- or 20-mg cancellation threshold for every urologic graft, flap or prosthesis.[6]
Perioperative Handoff
Record the baseline indication/dose, adrenal-risk assessment, route while NPO, planned stress regimen, monitoring, oral transition and who will adjust the plan if complications occur. Emergency treatment and chronic immunosuppression changes answer different clinical problems and should not become a single automatic order set.
References
1. Beuschlein F, Else T, Bancos I, et al. European Society of Endocrinology and Endocrine Society joint clinical guideline: diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. J Clin Endocrinol Metab. 2024;109:1657–1683. doi:10.1210/clinem/dgae250
2. Society for Endocrinology. Adrenal crisis information and emergency management. Official guidance.
3. National Institute for Health and Care Excellence. Adrenal insufficiency: identification and management. NG243, 2024. Recommendations, including section 1.7.
4. Corcoran TB, Myles PS, Forbes AB, et al. Dexamethasone and surgical-site infection. N Engl J Med. 2021;384:1731–1741. doi:10.1056/NEJMoa2028982
5. Wang AS, Armstrong EJ, Armstrong AW. Corticosteroids and wound healing: clinical considerations in the perioperative period. Am J Surg. 2013;206:410–417. doi:10.1016/j.amjsurg.2012.11.018
6. Adamina M, Kienle P, Chaparro M, et al. ECCO guidelines on therapeutics in ulcerative colitis: surgical treatment. J Crohns Colitis. 2026;20:jjag072. doi:10.1093/ecco-jcc/jjag072