ISTORICALLY, PATIENTS WHO are receiving oral glucocorticoids and undergo surgical procedures were administered supplemental intravenous steroids during the perioperative period. This practice remains controversial, however, for less invasive outpatient procedures such as those performed by hand surgeons on a routine basis. 1–5 To date, there are no evidence-based treatment guidelines that provide firm recommendations for the administration of perioperative steroids; rather, present management is based on case reports and observational studies. 2,3 In this article, we discuss the pathophysiology behind acute adrenal insufficiency, the stress response and its suppression, patients who may be at risk, the effect of inhaled and topical steroids, and published data that guide our practice concerning the administration of perioperative corticosteroids to patients undergoing outpatient hand surgery. PATHOPHYSIOLOGY The “HPA axis” consists of the hypothalamus, pituitary gland, and adrenal glands. The hypothalamus secretes corticotropin-releasing hormone (CRH) in response to stress, circulating blood levels of cortisol, and the sleep/ wake cycle. CRH then stimulates the pituitary to secrete adrenocorticotropic hormone (ACTH), which in turn stimulates the release of cortisol from the adrenal cortex. Cortisol is a negative inhibitor of both CRH and ACTH. It acts through various intracellular receptors to prevent the proliferation of T-cells, counteract insulin by increasing gluconeogenesis, promote breakdown of