A patient with Addison's disease on maintenance hydrocortisone 20 mg/10 mg daily is scheduled for a total hip replacement under general anaesthesia. What is the recommended perioperative steroid supplementation?

• A Continue routine dose only; no additional supplementation needed
• B Hydrocortisone 100 mg IV at induction, then 50 mg every 8 hours for 24 hours
• C Dexamethasone 8 mg IV at induction as equivalent replacement
• D Hydrocortisone 25 mg IV at induction, then 25 mg every 8 hours for 24 hours ✓

Explanation

For major surgery (>1 hour under general anaesthesia), the current evidence-based approach ('minor–moderate–major' stratification) recommends moderate supplementation: hydrocortisone 25 mg IV at induction then 25 mg 8-hourly for 24 hours (approximately matching peak cortisol output of ~150–200 mg/day in major physiological stress). Supraphysiological doses (100 mg bolus) are reserved for critical illness or major physiological stress such as emergency cardiac surgery. Dexamethasone lacks mineralocorticoid activity and cannot fully replace cortisol for adrenocortical insufficiency coverage.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.