Adrenal insufficiency in children: management for children undergoing surgical procedures

Objectives

Standardisation of the management of children with known or suspected adrenal insufficiency undergoing surgical procedures.

Scope

This clinical guidance should be used in children with known or suspected adrenal insufficiency who will undergo surgical procedures.

Conditions:

Children on daily replacement hydrocortisone treatment eg

Congenital adrenal hyperplasia
Congenital adrenal hypoplasia
Addison’s disease
Hypopituitarism eg congenital, brain tumour and post-radiotherapy

Children on high dose glucocorticoid treatment (Prednisolone, Deflazacort, Dexamethasone, Vamorolone) eg Inflammatory conditions like inflammatory arthritis, inflammatory bowel diseas, dDuchenne muscular dystrophy

Source for guidance

This clinical guidance adopts recommendations from the UK National Paediatric Adrenal Insufficiency Emergency Management Guidance developed by the British Society for Paediatric Endocrinology and Diabetes (2022). The British Society for Paediatric Endocrinology and Diabetes guidance has also been incorporated into the NICE guideline [NG243] Adrenal insufficiency: Identification and management (published 28^th August 2024).

MANAGEMENT OF CHILDREN WITH ADRENAL INSUFFICIENCY UNDERGOING MAJOR SURGERY (PROCEDURE EXPECTED TO LAST 90 MINUTES OR LONGER)

Major Surgery is defined as surgery last 90 minutes or longer, with variable recovery periods and expected delay in restarting oral intake.

(A) INDUCTION

At induction, give IV bolus hydrocortisone 2mg /kg (max 100 mg).

For premature infants and neonates < 28 days corrected gestational age, give IV bolus hydrocortisone 4 mg/kg.

(B) INTRAOPERATIVE

Start IV hydrocortisone infusion.

IV hydrocortisone infusion

Weight	Infusion rate (50 mg hydrocortisone in 50 ml 0.9% saline
≤10kg	1 ml/hour
10.1 to 20kg	2 ml/hour
20.1 to 40kg	4 ml/hour
40.1 to 70kg	6 ml/ hour
Over 70kg	8 ml/ hour

Consider more concentrated infusion in those needing fluid restriction (e.g. 100mg hydrocortisone in 50mls 0.9% saline).

The hydrocortisone infusion can be run alongside 0.9% sodium chloride, 5% glucose and PlasmaLyte solutions

(C) POST-OPERATIVE

Continue hydrocortisone infusion and change to oral sick day hydrocortisone when clinically stable and tolerating oral fluids / diet.

Stop hydrocortisone infusion 30 min after tolerating the first oral sick day dose.

Discuss duration of oral sick day dose with treating medical team.

Oral sick day hydrocortisone

Weight(kg)	Sick day hydrocortisone: Dose	Frequency
1	0.8 mg	4 x a day
2	1.2 mg	4 x a day
3	1.5 mg	4 x a day
4	2.0 mg	4 x a day
5	2.5 mg	4 x a day
6	2.5 mg	4 x a day
7	3.0 mg	4 x a day
8	3.0 mg	4 x a day
9	3.5 mg	4 x a day
10	4.0 mg	4 x a day
15	5.0 mg	4 x a day
20	6.0 mg	4 x a day
25	7.5 mg	4 x a day
30	7.5 mg	4 x a day
35	10.0 mg	4 x a day
40	10.0 mg	4 x a day
45	10.0 mg	4 x a day
50	10.0 mg	4 x a day
55	12.5 mg	4 x a day
60	12.5 mg	4 x a day
65	12.5 mg	4 x a day
70	15.0 mg	4 x a day
75	15.0 mg	4 x a day
80	15.0 mg	4 x a day
90	15.0 mg	4 x a day

MANAGEMENT OF CHILDREN WITH ADRENAL INSUFFICIENCY UNDERGOING MINOR SURGERY REQUIRING GENERAL ANAESTHESIA (PROCEDURE EXPECTED TO LAST LESS THAN 90 MINUTES)

Minor Surgery is defined as a procedure lasting less than 90 minutes and the patient is expected to be eating and drinking by the next meal. This may include procedures such as MRI scans, endoscopy, dental extractions under general anaesthetic or other day case procedures.

(A) INDUCTION

At induction, give IV bolus hydrocortisone 2mg /kg (max 100 mg).

For premature infants and neonates < 28 days corrected gestational age, give IV bolus hydrocortisone 4 mg/kg.

(B) POST-OPERATIVE

Oral sick day dose for 24 hours

Weight(kg)	Sick day hydrocortisone: Dose	Frequency
1	0.8 mg	4 x a day
2	1.2 mg	4 x a day
3	1.5 mg	4 x a day
4	2.0 mg	4 x a day
5	2.5 mg	4 x a day
6	2.5 mg	4 x a day
7	3.0 mg	4 x a day
8	3.0 mg	4 x a day
9	3.5 mg	4 x a day
10	4.0 mg	4 x a day
15	5.0 mg	4 x a day
20	6.0 mg	4 x a day
25	7.5 mg	4 x a day
30	7.5 mg	4 x a day
35	10.0 mg	4 x a day
40	10.0 mg	4 x a day
45	10.0 mg	4 x a day
50	10.0 mg	4 x a day
55	12.5 mg	4 x a day
60	12.5 mg	4 x a day
65	12.5 mg	4 x a day
70	15.0 mg	4 x a day
75	15.0 mg	4 x a day
80	15.0 mg	4 x a day
90	15.0 mg	4 x a day

MANAGEMENT OF CHILDREN WITH ADRENAL INSUFFICIENCY UNDERGOING MINOR SURGERY NOT REQUIRING GENERAL ANAESTHESIA

Minor surgery is defined as a procedure lasting less than 90 minutes and the patient is expected to be eating and drinking by the next meal.

For example:

Skin biopsy under local anaesthetic
Minor dental procedures eg filling tooth, tooth extraction (no general anaesthesia)
Non-anaesthetic sedation (eg chloral hydrate) for MRI

Give oral sick day dose on the day of the procedure and continue for 24 hours.

If in pain after 24 hours, patient to contact treating medical team and may need to continue oral sick day dose.