Table 3.

Recommended doses for intra-operative and postoperative steroid cover in adults receiving adrenosuppressive doses of steroids (high dose inhaled steroids, or those on combined inhaled steroids and interfering drugs; prednisolone equivalent ≥5 mg for 4 weeks or longer)

Intra-operative steroid replacementPostoperative steroid replacement
Major surgeryHydrocortisone 100 mg intravenously at induction, followed by immediate initiation of a continuous infusion of hydrocortisone at 200 mg.24 h-1
Alternatively, hydrocortisone 50 mg im 6-hourly
Alternatively, dexamethasone 6–8 mg intravenously, if used, will suffice for 24 h
Hydrocortisone 200 mg.24 h-1 by intravenous infusion while nil by mouth.
Alternatively, hydrocortisone 50 mg im 6-hourly
Resume enteral glucocorticoid at pre-surgical therapeutic dose if recovery is uncomplicated. Otherwise continue double oral dose for 48 h
Body surface and intermediate surgeryHydrocortisone 100 mg, intravenously at induction, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h-1
Alternatively, hydrocortisone 50 mg im 6-hourly
Alternatively, dexamethasone 6–8 mg intravenously, if used, will suffice for 24 h
Double regular glucocorticoid dose for 48 h, then continue usual treatment dose
Bowel procedures requiring laxatives/enemaContinue normal glucocorticoid dose. Equivalent intravenous dose if prolonged nil by mouth.
Treat as per primary adrenal insufficiency (see above) if concerned about HPA axis function, and risk of adrenal insufficiency
Labour and vaginal deliveryHydrocortisone 100 mg intravenously at onset of labour, followed by immediate initiation of a continuous infusion of hydrocortisone 200 mg.24 h-1
Alternatively, hydrocortisone 100 mg intramuscularly followed by 50 mg every 6 h im
Caesarean sectionSee major surgery
  • In severe obesity consider substituting 50 mg hydrocortisone with 100 mg hydrocortisone. While it is recommended hydrocortisone 50 mg every 6 h is given im, hydrocortisone can be given iv if patients are anticoagulated or clinically indicated.