Clinical Practice Guidelines

Adrenal insufficiency steroid replacement before and after surgery or procedure requiring GA

  • See also Adrenal crisis / Acute adrenal insufficiency CPG for full assessment and management guidelines of an unwell child with adrenal insufficiency.

    Background

    Children with known or suspected adrenal insufficiency require increased doses of hydrocortisone in the peri-operative period.  This is required to replace the body's usual 'stress' cortisol response in such a scenario; if adequate replacement is not given, an adrenal crisis may be precipitated.

    Recommended doses of 'Stress' Hydrocortisone (given i.m or i.v. ) at different ages*:

    Neonate - 6 weeks:25 mg stat initial dose, and then 5-10mg, 6 hourly
    6 weeks up to 3 years:25 mg stat initial dose, then 10mg, 6 hourly  
    Children aged between 3-12 years:50 mg stat initial dose, then 12.5 -25mg, 6 hourly
    (use 12.5mg as 6 hourly dose if aged 3-6 yrs or 25mg 6 hourly if aged >7yrs)
    Adolescents (13years+):100 mg stat initial dose, then 25mg, 6 hourly
    •  For elective surgery, the 'initial' dose can be given at induction of anaesthesia (when an i.v. line can be more easily sited), with 6 hourly parenteral dosing continuing thereafter.  
    • If the child requires emergency surgery, the initial dose should be administered without delay and ongoing doses continued 6 hourly thereafter.  Doses can be given i.m. if i.v. access is not readily available.
    • Children having a short GA for an elective non-invasive procedure (e.g. MRI) should have an initial 'stress' dose at induction.  If clinically well and tolerating oral intake after the procedure, they can then recommence their usual replacement therapy.

    *The doses outlined equate to approximately 50-75mg/m2 as a stat dose initially, followed by 50-75mg per m2/day divided in 4 doses (6 hourly).  These doses will also cover the patient's mineralocorticoid replacement over this dosing period.

    Transition to oral steroid replacement therapy:

    Please discuss with the endocrinology team who will advise on individual dosing schedules. 

    1. Hydrocortisone replacement:
      Once the child is stable and tolerating oral intake post-op, hydrocortisone cover can be changed to oral route.  Initial dosing can be given by tripling the child's usual hydrocortisone dose (where applicable) for ~48 hours, followed by double the usual dose for ~48 hours, followed by a return to maintenance therapy.

      If a child with suspected adrenal insufficiency has not previously been on replacement therapy, the initial 'stress' oral hydrocortisone replacement should be at a dose of between ~30-50mg/m2/day.  This can then be gradually reduced to maintenance levels over ~4-5 days. Usual replacement requirements are ~10-15 mg/m2/day for patients with primary adrenal insufficiency, or ~5-8 mg/m2/day in secondary adrenal insufficiency.

    2. Mineralocorticoid replacement: 
      Patients with primary adrenal insufficiency require mineralocorticoid as well as glucocorticoid replacement.  The mineralocorticoid activity of 'stress' parenteral doses of hydrocortisone will cover this requirement in the initial period.  Fludrocortisone (Florinef) replacement should be recommenced at usual maintenance doses once the patient transitions to oral therapy.  In a patient newly diagnosed with primary adrenal insufficiency, the endocrine team will advise on dosing (usually ~50-100mcg/day; higher doses required in neonates).


    Last updated May 2011