Surgery And Adrenal Insufficiency: Steroid Cover

Kasi Subbiah

Sep 20

4 min read

Updated: Sep 28

Surgery is planned stress. That is the useful way to think about it.

A procedure may be minor, major, quick, slow, local, regional or general anaesthetic. But from the body's point of view, surgery is still a biological event: fasting, anaesthetic drugs, tissue stress, blood pressure shifts, pain, inflammation, sometimes nausea, and sometimes infection.

A person with normal adrenal function responds by producing more cortisol. It happens automatically, like a well-trained backstage crew changing the scenery while the audience watches the play. In adrenal insufficiency, the backstage crew needs a written rota. That rota is surgical steroid cover.

How this page differs from sick day rules

Sick day rules are for illness at home: fever, infection, vomiting, diarrhoea, and when to inject. Surgical steroid cover is different. It is about preventing adrenal crisis during planned procedures, anaesthesia, fasting, bowel preparation, hospital admission and recovery.

The aim is not just to take a bit extra. The aim is to match steroid cover to the level of surgical stress and to make sure the hospital team knows exactly what is needed.

Who needs surgical steroid cover

Primary adrenal insufficiency, including Addison's disease.
Secondary adrenal insufficiency due to pituitary or hypothalamic disease.
Congenital adrenal hyperplasia.
Steroid-induced adrenal insufficiency.
Current or recent adrenosuppressive steroid therapy where the hypothalamic-pituitary-adrenal axis may not respond normally.

Patients taking long-term prednisolone-equivalent doses around 4 to 6 mg daily or more may need to be considered at risk, depending on duration and clinical context. The safest approach is for the pre-operative and endocrine teams to decide before the day of surgery.

Before surgery make the diagnosis visible

Before any planned procedure, the surgical team, anaesthetist and pre-assessment clinic should know that the patient has adrenal insufficiency or is steroid-dependent.

Steroid emergency card.
Current medication list.
Usual steroid doses and timings.
Emergency hydrocortisone injection kit.
Endocrine letters or surgical steroid guidance.
Contact details for the endocrine team.
A clear note that steroid replacement is time-critical.

It is reasonable to ask that adrenal insufficiency is clearly recorded in the hospital notes and drug chart. This is not fussiness. It is good risk management wearing sensible shoes.

Minor procedures under local anaesthetic

For minor procedures under local anaesthetic, some guidance recommends an additional oral steroid dose before the procedure and sometimes another after it.

For example, the ADSHG surgical guidance suggests an additional oral dose of 10 mg hydrocortisone or 2.5 mg prednisolone about 60 minutes before a minor local procedure, and a similar additional dose afterwards, with return to usual dosing the next day if well.

This should be individualised. A small skin procedure is not the same as a long dental extraction in someone who is anxious, fasting, infected or unwell.

Bowel preparation

Bowel preparation deserves special respect. It can cause fluid loss, salt disturbance, reduced oral intake and poor absorption of tablets. For patients with adrenal insufficiency, especially those dependent on fludrocortisone or vasopressin/desmopressin, this may be risky.

The ADSHG guidance recommends bowel preparation under hospital clinical supervision, with consideration of intravenous fluids and injected hydrocortisone during preparation in higher-risk situations. This is one of those areas where the procedure may be tomorrow, but the risk begins today.

Surgery under general or regional anaesthesia

For surgery under general or regional anaesthesia, UK peri-operative guidance commonly recommends hydrocortisone 100 mg intravenously at induction, followed by hydrocortisone 200 mg over 24 hours by continuous infusion, or 50 mg IV or IM every 6 hours.

This applies to significant procedures including operations under anaesthesia, joint replacement, endoscopy requiring anaesthetic-level stress cover, IVF egg collection, and caesarean section.

While the patient is nil-by-mouth or vomiting, steroid cover should continue by injection or infusion. Once clinically stable and eating, the patient can usually move back to oral steroid cover at a temporarily increased dose, then step down to maintenance.

After surgery recovery is still stress

The stress response does not stop the moment the operation ends. Pain, nausea, infection, bleeding, delayed eating, low blood pressure or fever can all increase cortisol needs.

Usual Steroid	Temporary post-op oral cover
Hydrocortisone	Around 40 mg daily in 2 to 3 divided doses for about 24 to 48 hours, depending on procedure and recovery.
Prednisolone	Around 10 mg daily in 1 to 2 divided doses for about 24 to 48 hours, depending on procedure and recovery.

If complications occur, such as fever, vomiting, hypotension or delayed recovery, return to normal dosing should be delayed and medical review is needed.

Tapering back down

Duration of Increased Dose	Typical Taper Approach
Less than 48 hours	Often return to usual maintenance dose if clinically well.
3 to 7 days	Reduce gradually over 1 to 2 days.
More than 1 week	Reduce gradually over about a week.

If symptoms return while reducing, patients should seek medical advice. The plan should fit the person, not just the table.

Hospital safety points

Am I listed first on the operating list where appropriate?
Is adrenal insufficiency clearly written on the drug chart?
Has the anaesthetist reviewed my steroid plan?
Is IV hydrocortisone prescribed while I am nil-by-mouth?
Are blood pressure, sodium, potassium and glucose being monitored?
Has an endocrine review been requested?
What dose should I take after discharge, and for how long?

This is not about taking over the ward round. It is about making sure the important information is visible at the right moment.

When things do not go to plan

If a patient becomes hypotensive, drowsy, confused, severely weak, peripherally shut down, or clinically deteriorates after surgery, adrenal crisis should be considered. Emergency hydrocortisone should not be delayed while waiting for blood tests if adrenal crisis is suspected.

Hydrocortisone is time-critical treatment in this setting.

Closing thought

Surgery with adrenal insufficiency can be managed safely, but it works best when the plan is made before the cannula goes in and the theatre clock starts ticking.

The key is simple: tell the team early, make the diagnosis visible, ensure steroid cover is prescribed, continue cover while nil-by-mouth or vomiting, and step back down only when clinically stable. Good peri-operative steroid planning is not dramatic. That is precisely the point.