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  • Corticosurrenal production under control of the hypothalamic–pituitary axis of:
    • Glucocorticosteroids (cortisol [= hydrocortisone] and corticosterone)
    • Mineralocorticosteroids (aldosterone)
  • Basal corticosteroid production in an adult patient = 5–10 mg/m2 per day of cortisol (equivalent to 5–7 mg prednisone or 20–30 mg hydrocortisone for an average adult)
  • If extrinsic steroid therapy administered, negative feedback to the hypothalamic–pituitary axis and inhibition of the corticoadrenal production
  • In case of stress (such as surgery, disease, physical exertion, pregnancy), the normal protective surge in systemic cortisol will be inhibited, thus putting the patient at risk of acute adrenal insufficiency
  • Normal daily secretion of cortisol in the perioperative period (about 72 hours):
    • Minor surgery: 25 mg
    • Moderate surgery: 50–75 mg
    • Major surgery: 100–150 mg
  • Stress-dose steroid replacement should be commensurate to the need; if excessive, risk of infectious complications, delayed wound healing, and disturbed metabolic regulation (hyperglycemia)

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Corticosteroids as chronic therapy = major reason for adrenal insufficiency.

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Even possible for short therapy (5 days) or low dose (5 mg per day of prednisone).

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Table Graphic Jump Location
Table 11-1 Corticosteroid Equivalent Doses
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Note that dexamethasone should not be used to replace intrinsic steroid production, as it has no mineralocorticoid effect.

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Minor Surgical Stress (e.g., Hand Surgery, Hernia)

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Take the usual steroid therapy on the morning of surgery.

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Possibly, on induction: 25 mg hydrocortisone IV or 5 mg methylprednisolone IV.

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Moderate Surgical Stress (e.g., Hysterectomy, Cholecystectomy)

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  • Elective surgery: usual corticotherapy on the morning of surgery, 25 mg hydrocortisone IV q8 hours for 48 hours at the most
  • Emergency surgery: on induction, 25–50 mg hydrocortisone IV, and then 25–50 mg hydrocortisone IV q8 hours

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After surgery, usual therapy or equivalence with hydrocortisone IV q8 hours if unable to take po.

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Major Surgical Stress (e.g., Major Trauma, Prolonged Surgery, or Surgery Where There Is Delayed Oral Intake, Such as Esophagectomy, Cardiac Surgery)

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  • Elective surgery: usual steroid therapy on the morning of surgery, 50 mg hydrocortisone IV on induction, and then 50 mg hydrocortisone IV q8 hours until patient able to resume usual therapy
  • Emergency surgery: 100 mg hydrocortisone IV on induction, and then 50 mg hydrocortisone IV q8 hours until patient able to resume usual therapy

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Usual treatment: hydrocortisone and fludrocortisone (glucocorticosteroids and mineralocorticosteroids).

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  • The day before: usual therapy
  • The morning of surgery:
    • Premedication with 9-α-fludrocortisone 50 μg po
    • During surgery: hydrocortisone 50 mg IV, and then 10–20 mg/h
  • After surgery if ...

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