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Corticosteroid (Systemic — IV) Pregnancy: Use with caution — short-term perioperative use acceptable; risk of fetal adrenal suppression with prolonged high-dose use; neonatal monitoring required

Methylprednisolone (Surgical — Anti-Inflammatory)

Brand names: Solu-Medrone, Depo-Medrone

Adult dose

Dose: Perioperative stress dosing (steroid-dependent patients): 25–100 mg IV at induction then usual oral dose resumed. Spinal surgery (NASCIS protocol — controversial): 30 mg/kg IV over 15 min then 5.4 mg/kg/hour for 23 hours. Acute organ rejection: 0.5–1 g IV over 30 min (pulse dose)
Route: IV
Frequency: Variable by indication
Max: 1 g/dose (pulse therapy)
4× more potent than hydrocortisone, 5× more potent than prednisolone on weight basis. Minimal mineralocorticoid activity vs hydrocortisone. Used perioperatively in steroid-dependent patients to prevent adrenal crisis. NASCIS II/III spinal cord injury protocol is highly controversial — most current guidelines do NOT recommend routine use.

Paediatric dose

Dose: 0.5–1 mg/kg
Route: IV
Frequency: Every 6–24 hours by indication
Max: 1 g per dose (pulse)
Paediatric surgical stress dosing: 1–2 mg/kg IV at induction for steroid-dependent patients. Acute asthma in surgical patients: 1–2 mg/kg IV (max 40 mg in children <2 years).

Dose adjustments

Renal

No dose adjustment required.

Hepatic

Caution in severe hepatic impairment — increased bioavailability and prolonged effect.

Paediatric weight-based calculator

Paediatric surgical stress dosing: 1–2 mg/kg IV at induction for steroid-dependent patients. Acute asthma in surgical patients: 1–2 mg/kg IV (max 40 mg in children <2 years).

Clinical pearls

  • Perioperative steroid cover: patients on >5 mg/day prednisolone for >4 weeks have suppressed HPA axis — give supplemental IV methylprednisolone or hydrocortisone at induction (minor surgery: 25 mg, moderate: 50 mg, major: 100 mg IV) to prevent Addisonian crisis
  • NASCIS spinal cord injury protocol — current consensus: the original NASCIS II (1990) and NASCIS III (1997) data showing benefit were re-analysed and found methodologically flawed; current AOSpine/NICE guidance does NOT recommend routine high-dose methylprednisolone for acute traumatic spinal cord injury
  • Wound healing impairment: high-dose perioperative steroids impair collagen synthesis and fibroblast function — important consideration in colorectal, abdominal and plastic surgery; anastomotic leak risk increased

Contraindications

  • Systemic infection without adequate antimicrobial cover
  • Live vaccines (during and for 3 months after)
  • Epidural route (Depo-Medrone contains polyethylene glycol — neurotoxic intrathecally)

Side effects

  • Hyperglycaemia
  • Impaired wound healing
  • Infection susceptibility
  • Adrenal suppression (prolonged use)
  • GI bleeding (NSAIDs co-administration risk)
  • Psychiatric effects (high doses)
  • Fluid retention
  • Hypertension

Interactions

  • NSAIDs (GI bleeding — additive)
  • Antidiabetics (hyperglycaemia antagonism — insulin dose increase required)
  • Warfarin (variable — usually increases INR; monitor)
  • Ciclosporin (both increase each other's levels — mutual interaction)

Monitoring

  • Blood glucose (4-hourly perioperatively — hyperglycaemia common)
  • Blood pressure
  • Wound healing (post-operatively)
  • Signs of infection (masked by immunosuppression)

Reference: BNFc; BNF 90; RCUK Perioperative Steroid Guidelines 2020; NICE NG158; AOSpine Guidelines on Spinal Cord Injury 2017; BNFc. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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