Adrenal insufficiency, protocol for children who require surgery, procedure or dental extractions

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Objectives

This protocol standardises the steroid management of children with adrenal insufficiency who require surgery, dental extractions or other procedures performed.

 

Scope

This protocol should be used for children with adrenal insufficiency when they need to undergo surgery, dental extractions or other procedures. 

Conditions: Children on daily replacement hydrocortisone treatment, eg.

  • Congenital Adrenal Hyperplasia
  • Congenital Adrenal Hypoplasia
  • Adrenal Insufficiency
  • Multiple Pituitary Hormone Deficiency
Minor Procedures/Daycase

Summary

  • Anaesthetic usually under 20mins duration (up to 1 hour)
  • Examples include endoscopy, jejunal biopsy, adenotonsillectomy, grommet insertion and dental extraction
  • Usually able to eat and drink within 4 hours post-procedure

Steroid cover

  1. At induction, patient should be have IV bolus of hydrocortisone.
  2. Post-operatively, give double the largest usual hydrocortisone dose when able to tolerate orally and  administer three times daily for 48 hrs.
    (eg if normally on 10mg morning, 10mg afternoon and 5mg evening, then give 20mg threes times a day)
    • if oral hydrocortisone not tolerated, commence IV hydrocortisone infusion
Major Surgery and Emergency Procedures

 Please inform endocrine nurse or registrar at least 48 hours prior to procedure to discuss steroid   cover for the operation and post-operative period,  
 preferably at pre-assessment or preceding clinic appointment

Endocrine nurse - page 18005  ext 84568   Endocrine registrar - page 18301

 

Steroid cover

  1. Patient should have an IV bolus of hydrocortisone at induction of anaesthesia and then commenced onto hydrocortisone infusion in theatre as below.
  2. Infusion should continue until patient is well and able to tolerate oral hydrocortisone.
  3. Give double the largest usual hydrocortisone dose and if tolerated discontinue infusion 1-2 hours later.
  4. Continue with doubled largest dose hydrocortisone and  administer three times daily for 48 hrs
    (eg if normally on 10mg morning, 10mg afternoon and 5mg evening, then give 20mg threes times a day)

Any concerns contact Endocrine Team

DO NOT DISCHARGE HOME without discussing with endocrine team

Age Hydrocortisone Bolus 
[given at induction]
Hydrocortisone infusion 
[50mg hydrocortisone in 50mls 0.9% saline]
<6months 12.5mg 1ml/hr
6 months-5years 25mg 1ml/hr
5-10years 50mg 2ml/hr
>10years 100mg 3ml/hr

 

Algorithm

Editorial Information

Last reviewed: 01 October 2019

Next review: 01 October 2021

Author(s): Guftar Shaikh

Approved By: Paediatric Clinical Effectiveness & Risk Committee