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Download citation file: CHRONIC steroid therapy is a cornerstone treatment for many common conditions, including inflammatory bowel disease, rheumatologic disease, reactive airway disease, and immunosuppression for transplant recipients. Patients on chronic steroid therapy may develop secondary adrenal insufficiency that can manifest as full-blown adrenal crisis in the perioperative period. When these patients present for surgery, the anesthesiologist must decide whether to administer perioperative stress-dose steroids to mitigate this rare but potentially fatal complication of chronic steroid use. In doing so, the patient’s risk for adrenal crisis must be weighed against the risks of unnecessary steroid supplementation. Unfortunately, this decision is not always clear-cut, because even the recommendations found in major textbooks are confusing, inconsistent, and lacking in class A and B evidence (table 1). Despite the lack of standardization and the widespread use of perioperative stress-dose steroids observed in clinical practice, a recent search of the Anesthesia Closed Claims Project database containing 11,247 claim narratives using the terms ‘stress dose,’ ‘Cushing,’ ‘Addison,’ and ‘adrenal insufficiency’ revealed that failure to administer stress steroids generated only two claims that resulted in liability payments, and both of these cases were complicated by other issues (written personal communication, Karen L. It is unclear whether this paucity of claims is due to underdiagnosis of adrenal crisis or overtreatment of perioperative patients with steroids. We now review and evaluate the current data on the use of perioperative stress-dose steroids and propose approaches to administration and dosing. Published Perioperative Steroid Dosing Recommendations. Acute physiologic or psychologic stress activates the hypothalamic-pituitary-adrenal axis (HPAA). 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