Day Before Surgery |
Advise usual oral steroid treatment and diet |
Morning of Surgery |
Hypoglycaemia and hypotension in this setting may suggest inadequate hydrocortisone replacement. If CBG <3.5mmol/L give 2ml/kg 10% dextrose IV to treat hypoglycaemia followed by maintenance IV fluids (0.9% saline + 5% dextrose). Give a stress dose of IV hydrocortisone (2mg/kg up to 100mg). Record blood pressure on admission and only check again if symptomatic before going to theatre (i.e. dizzy, lethargic, syncope). If the patient is hypotensive (systolic blood pressure below recommended threshold on appropriate age PEWS chart) then give a 10ml/kg fluid bolus and stress dose IV hydrocortisone (2mg/kg, max 100mg). A stress dose of hydrocortisone should only be given once for hypoglycaemia and/or hypotension pre-operatively. The patient should then be discussed with the local endocrinology team about further management. |
During Surgery |
At induction of anaesthesia give 1mg/kg IV hydrocortisone (max 100mg) (18). An induction dose of hydrocortisone should be given in addition to any pre-operative stress dose of IV hydrocortisone. This is to cover the additional stress of induction of anaesthesia, surgery and recovery. Monitor blood glucose levels hourly. |
After Surgery |
Once the child is eating and drinking they can be converted to oral hydrocortisone at 30mg/m2/day in 4 divided doses for 24 hours (16).After this time they can resume their usual steroid medication. |
Day Before Surgery |
Advise usual oral steroid treatment and diet |
Morning of Surgery |
Hypoglycaemia and hypotension in this setting may suggest inadequate hydrocortisone replacement. If CBG <3.5 mmol/L give 2ml/kg 10% dextrose to treat hypoglycaemia followed by maintenance IV fluids (0.9% saline + 5% dextrose). Give a stress dose of IV hydrocortisone (2mg/kg - max 100mg) Record blood pressure on admission and if symptomatic (i.e. dizzy, lethargic, syncope) before going to theatre. If the patient is hypotensive (systolic blood pressure below recommended threshold on appropriate age PEWS chart) then give a 10ml/kg fluid bolus and stress dose IV hydrocortisone (2mg/kg - max 100mg). A stress dose of hydrocortisone should only be given once for hypoglycaemia and/or hypotension pre-operatively. The patient should then be discussed with the local endocrinology team about further management. |
During Surgery |
At induction of anaesthesia give 2mg/kg IV hydrocortisone (max 100mg) (19). Start maintenance IV fluids (0.9% saline and 5% dextrose). |
After Surgery |
Continue 2mg/kg IV hydrocortisone (max 100mg) 6 hourly until the child is eating and drinking (19). If the child is seriously unwell, septic or haemodynamically unstable then consider an IV hydrocortisone infusion, for example children admitted to PICU post-operatively (appendix 4) (16,20). Monitor CBG 2 hourly until the child is eating and drinking. Monitor blood pressure hourly. Once the child is eating and drinking they can be converted to oral hydrocortisone 50mg/m2/day in 4 divided doses for 48 hours (17). After this time they can restart their usual steroid medication. |
Day Before Surgery |
Advise usual oral steroid treatment and diet |
Morning of Surgery |
Children should be placed first on the morning list, if possible, to minimise dehydration and fasting times. Children with AI on maintenance hydrocortisone: Take an increased dose of oral hydrocortisone pre-operatively at 30mg/m2/day in 4 divided doses. Children at risk of AS on daily oral prednisolone: Take a double dose of prednisolone on the morning of surgery. Children at risk of AS on inhaled glucocorticoids or other oral formulation: Take stress dose hydrocortisone at 30mg/m2/day in 4 divided doses starting at 0600 on the morning of surgery. |
During Surgery |
N/A |
After Surgery |
Once the child is eating and drinking they can take oral hydrocortisone 30mg/m2/day in 4 divided doses for 24 hours. After this time they can restart their usual steroid medication. Children on oral prednisolone can resume their normal dose the following day. If at any point during or after the procedure the child is unwell or vomiting, give emergency intramuscular hydrocortisone (appendix 5) and arrange transfer to hospital for further assessment. |
cf |
Total dose over 24 hours (mg) |
Infusion rate (ml/hr) |
Up to 10kg |
25 |
1 |
11-20kg |
50 |
2 |
Over 20kg Pre-Pubertal Pubertal |
100 150 |
4.1 6.2 |
Age |
IM Hydrocortisone Dose (mg) |
<1 year |
25 |
1-5 years |
50 |
>5 years |
100 |
Document Version:
1.0 Lead Author: Dr Anitha Kumaran, Consultant in Paediatric Endocrinology and Diabetes Additional Author: Dr Gemma Watts, ST6 Paediatrics |
Approving Network:
Wessex Paediatric Endocrine Network Date of Approval: 02/2023 Review Date: 02/2024 |
PIER Contact |
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