A 30-year-old woman with secondary adrenal insufficiency is managed with hydrocortisone replacement. She is scheduled for an elective surgery. The appropriate perioperative steroid management is based on which physiological principle?

• A Exogenous corticosteroids suppress T-cell function, requiring perioperative dose reduction to prevent infection
• B The HPA axis produces a stress response proportional to surgical trauma; suppressed HPA axis cannot mount this response, risking adrenal crisis ✓
• C Hydrocortisone inhibits platelet aggregation and must be discontinued before surgery
• D Major surgery causes ACTH suppression that requires corticosteroid bridging to prevent thyroid storm

Explanation

During physiological stress (surgery, infection, trauma), the intact HPA axis produces 3–10 times the basal cortisol output. Patients on long-term exogenous corticosteroids (or those with primary/secondary adrenal insufficiency) have suppressed HPA axes and cannot mount this stress response. Without adequate cortisol, peripheral vasodilation, reduced vascular sensitivity to catecholamines, and impaired gluconeogenesis can precipitate an Addisonian (adrenal) crisis with cardiovascular collapse. Standard perioperative management involves stress-dose hydrocortisone (50–100 mg IV pre-incision, then 25–50 mg q8h for 24–48 hours for major surgery), tapered to baseline over 1–3 days.

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

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