Steroid precautions for hypoadrenal patients undergoing surgery or other procedures

Patients with hypoadrenalism of any cause require special precautions before undergoing invasive procedures. This advice applies to patients with Addison's disease, hypopituitarism, or long term adrenal suppression and covers procedures such as endoscopy, dental work and major surgery.

Major surgery with prolonged recovery time e.g. cardiac surgery or any condition requiring admission to an intensive care unit.

Major surgery or ITU admissions will require 100mg intra-muscular hydrocortisone on induction of anaesthetic/admission to ITU, to be repeated until the patient is discharged and can eat and drink normally. Patients should then usually stay on double their usual dose of glucocorticoids for at least 48 hours depending on their clinical condition. Doses can then usually be tailed down towards normal

Major surgery with rapid recovery e.g. caesarian section.

Major procedures e.g. caesarian section, joint replacement or other operations requiring a general anaesthetic always require parental steroids. As a rule, patients should take their usual doses the day before surgery, and on the morning of surgery for later procedures. 100mg intra-muscular hydrocortisone should then be administered on induction of the anaesthetic, and the dose repeated 6 hourly thereafter for 24-48 hours or until the patient is able to eat and drink normally. Patients should then typically take double their usual dose for 48hours, or until they are feeling back to normal, at which they should resume their usual dose.

Labour and vaginal birth

Labour and delivery requires 100mg intra-muscular hydrocortisone to be given at the start of labour, then every 6 hours until the baby is delivered. Most people then need double their usual dose for 24-48 hours and then if they are well, revert to their usual pre-pregnancy doses.

 Minor surgery e.g. cataract or hernia repair

Invasive procudures or operations not requiring a prolonged recover time e.g. major dental work under general anaesthetic, cataract surgery, hernia repair or endoscopy, will usually require a single dose of 100mg intra-muscular hydrocortisone at the start of the procedure, followed by double the patient's usual dose of oral steroids for 24 hours.

Invasive bowel procedures requiring laxatives

Colonoscopy and barium enema requiring extended bowel preparation can be difficult to plan for due to unpredictable absorption of oral doses. Ideally, patients should be admitted for intravenous fluids and 6 hourly intra-muscular hydrocortisone throughout the purgative phase until the start of the procedure. Patients should then take double their usual dose for 24 hours, and then can usually revert to their usual dose. 

Other invasive procedures e.g. endoscopy

Invasive procudures such as endoscopy will usually require a single dose of 100mg intra-muscular hydrocortisone to be given at the start of the procedure, followed by double the patient's usual dose of oral steroids for 24 hours only.

Very minor procedures e.g. skin biopsy under local anaesthetic.

As a rule, very minor procedures will not require any special precautions.

Minor Dental work

No extra precautions are usually required for minor dental work e.g. scale and polish, or filling replacement.

Dental surgery e.g. root canal work under local anaesthetic

Patients undergoing dental surgery under local anaesthetic should take double their usual dose before their procedure and for 24 hours afterwards.  

 Major dental surgery under general anaesthetic

Major dental work e.g. extraction under general anaesthetic requires 100mg inta-muscular hydrocortisone to be given at induction of the anaesthetic. Patients should then take double their usual dose for 24 hours after the procedure.