Perioperative Evaluation and Treatment of Adrenal Insufficiency

Surgery in patients with primary adrenal insufficiency can precipitate acute adrenal insufficiency, a potentially life-threatening complication. Acute adrenal insufficiency, however, can be prevented by the perioperative administration of a short activity of stress dose steroids. Patients with secondary adrenal insufficiency due to exogenous steroid administration may also be at risk for perioperative acute adrenal insufficiency due to suppression of the hypothalamic-pituitary-adrenal axis. When these patients present for preoperative evaluation, the risk for acute adrenal insufficiency must be weighed against the risk of administering higher steroid doses in the perioperative period. Inconsistencies in the published literature and the widespread use of perioperative dexamethasone can make decisions about perioperative stress dose steroid administration challenging. The following activity suggests a rational strategy for the perioperative management of both patients with known adrenal insufficiency and those at risk for hypothalamic-pituitary-adrenal axis suppression due to exogenous steroid administration.

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Availability

On-Demand

Expires on May 16, 2026

Cost

Member: $0.00

Non-Member: $95.00

Credit Offered

2 CME Credits

2 ABIM-MOC Points

2 Participation Credits

Overview
Overview
Faculty
Accreditation
Recommended

Learning Objectives
After completing this activity, learners should be able to:

Differentiate primary and secondary adrenal insufficiency with regard to etiology, pathophysiology, and presentation.
Categorize exogenous steroids by their relative glucocorticoid and mineralocorticoid potency.
Risk-stratify patients for perioperative acute adrenal insufficiency based on the combination of patient-specific risk and degree of surgical stress.
Selectively order preoperative hypothalamic-pituitary-adrenal axis testing.
Use a risk matrix to develop a perioperative steroid management plan.
Consider the implications of perioperative dexamethasone administration on the stress steroid management plan.

If you are a Program Director and would like to grant access to your trainees, please reach out to education@hospitalmedicine.org for an academic access code.

Description
Surgery in patients with primary adrenal insufficiency can precipitate acute adrenal insufficiency, a potentially life-threatening complication. Acute adrenal insufficiency, however, can be prevented by the perioperative administration of a short activity of stress dose steroids. Patients with secondary adrenal insufficiency due to exogenous steroid administration may also be at risk for perioperative acute adrenal insufficiency due to suppression of the hypothalamic-pituitary-adrenal axis. When these patients present for preoperative evaluation, the risk for acute adrenal insufficiency must be weighed against the risk of administering higher steroid doses in the perioperative period. Inconsistencies in the published literature and the widespread use of perioperative dexamethasone can make decisions about perioperative stress dose steroid administration challenging. The following activity suggests a rational strategy for the perioperative management of both patients with known adrenal insufficiency and those at risk for hypothalamic-pituitary-adrenal axis suppression due to exogenous steroid administration.

Learning Objectives
After completing this activity, learners should be able to:

Differentiate primary and secondary adrenal insufficiency with regard to etiology, pathophysiology, and presentation.
Categorize exogenous steroids by their relative glucocorticoid and mineralocorticoid potency.
Risk-stratify patients for perioperative acute adrenal insufficiency based on the combination of patient-specific risk and degree of surgical stress.
Selectively order preoperative hypothalamic-pituitary-adrenal axis testing.
Use a risk matrix to develop a perioperative steroid management plan.
Consider the implications of perioperative dexamethasone administration on the stress steroid management plan.

If you are a Program Director and would like to grant access to your trainees, please reach out to education@hospitalmedicine.org for an academic access code.

Faculty

Jason F. Shiffermiller, MD, MPH
Alana E. Sigmund, MD, FHM
- Dr. Sigmund reports owning stock in CVS, Briston Myers Squibb, Walgreen's, and Pfizer.
Kurt Pfeifer, MD, FACP, SFHM, DFPM
Leonard Feldman, MD, FACP, FAAP, MHM

Faculty Disclosures
The faculty and planners of these activities have no relevant relationships to disclose. All relevant relationships were mitigated prior to the start of this activity.

Conflict of Interest Disclosure Policy
In accordance with the ACCME Standards for Commercial Support, SHM requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest. SHM mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs. All relevant financial relationships shall be disclosed to participants prior to the start of the activity.

Furthermore, SHM seeks to verify that all scientific research referred to, reported, or used in a continuing medical education (CME) activity conforms to the generally accepted standards of experimental design, data collection, and analysis. SHM is committed to providing its learners with high-quality CME activities that promote improvements in healthcare and not those of a commercial interest.

Accreditation Statement
The Society of Hospital Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CME Credit Statement
The Society of Hospital Medicine designates this online activity for a maximum of 2.00 AMA PRA Category 1 Credit^TM. Physicians should claim only credit commensurate with the extent of their participation in the activity.

MOC Credit Statement
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 2.00 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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