What is the recommended hydrocortisone (cortisol) loading dose for a patient with bronchial asthma not in exacerbation undergoing an elective cesarean section (CS)?

Hydrocortisone Loading Dose for Elective Cesarean Section in Asthma Patients Not in Exacerbation

For a patient with bronchial asthma not in exacerbation undergoing elective cesarean section, administer hydrocortisone 100 mg IV at induction ONLY if the patient has been on oral systemic corticosteroids (≥7.5 mg prednisone daily) for at least 2 weeks within the past 6 months, followed immediately by a continuous infusion of 200 mg over 24 hours. 1, 2

Key Decision Point: Does This Patient Need Stress-Dose Steroids?

The critical question is whether this asthma patient has hypothalamic-pituitary-adrenal (HPA) axis suppression requiring perioperative steroid coverage. Asthma alone, even with inhaled corticosteroids, does NOT require stress-dose hydrocortisone for surgery. 2

Patients Who REQUIRE Hydrocortisone Loading:

• Oral systemic corticosteroids ≥7.5 mg prednisone daily for ≥2 weeks within the past 6 months 1, 2
• Prednisone equivalent ≥5 mg daily for ≥4 weeks (represents adrenal suppression in approximately one-third to one-half of adults) 1, 3
• Any patient with documented adrenal insufficiency 1, 4

Patients Who DO NOT Require Hydrocortisone Loading:

• Patients on inhaled corticosteroids alone (even high-dose), though selected patients on very high-dose ICS may require consideration 2
• Asthma not in exacerbation with no recent systemic steroid use 1
• Well-controlled asthma on standard maintenance therapy 2

Standard Protocol When Hydrocortisone IS Indicated

Intraoperative Management:

• Hydrocortisone 100 mg IV bolus at surgical induction (before incision) 1, 3, 4
• Immediately initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours (approximately 8.3 mg/hour) 1, 3, 4
• Alternative regimen: Hydrocortisone 50 mg IV or IM every 6 hours (though continuous infusion is preferred for stable cortisol levels) 1, 4

The Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology UK classify cesarean section as major surgery requiring the same stress-dose coverage as other major procedures. 1, 4

Postoperative Management:

• Continue hydrocortisone 200 mg/24h IV infusion while NPO or experiencing vomiting 1, 3, 4
• Once tolerating oral intake: Resume oral glucocorticoid at double the pre-surgical dose for 48 hours if recovery is uncomplicated 1, 3, 4
• If complications occur: Continue doubled oral dose for up to one week 1, 3, 4

Asthma-Specific Perioperative Considerations

Continue Regular Asthma Medications:

• All regular asthma medications should be continued through the perioperative period, including on the day of surgery 2
• Inhaled corticosteroids should NOT be stopped and do not contribute to HPA axis suppression requiring stress-dose coverage 2
• Bronchodilators should be available and administered as needed 1

Regional Anesthesia Preferred:

• Epidural or spinal anesthesia is preferred over general anesthesia when possible to avoid airway manipulation and reduce bronchospasm risk 1, 2
• If general anesthesia is required, extubate while fully awake unless medically contraindicated 2

Critical Pitfalls to Avoid

Do NOT Give Stress-Dose Steroids Unnecessarily:

The most common error is administering stress-dose hydrocortisone to ALL asthma patients undergoing surgery. 2 This exposes patients to unnecessary hyperglycemia (insulin requirements may increase 40-60%), infection risk, and other steroid-related complications without benefit. 3

Avoid Bronchospasm Triggers:

• Do NOT use ergometrine or prostaglandin F2α for post-partum hemorrhage in asthma patients, as both can cause severe bronchospasm 1
• Oxytocin is the uterotonic of choice for active management of third stage of labor 1

Medication-Specific Caution:

• In aspirin-induced asthma specifically, hydrocortisone IV bolus may paradoxically cause transient bronchoconstriction; consider methylprednisolone, dexamethasone, or betamethasone instead 5
• However, this is a rare subtype and should not change management for typical asthma patients 5

Evidence Quality and Nuances

The 2020 UK guidelines from the Association of Anaesthetists, Royal College of Physicians, and Society for Endocrinology represent the highest quality evidence for perioperative steroid management. 1 These guidelines acknowledge limited evidence but strongly support supplementation in at-risk patients because adrenal crisis occurs at 6-8 per 100 patient-years in adrenal insufficiency, while short-term glucocorticoid supplementation has minimal long-term adverse consequences. 3

The ERS/TSANZ 2020 guidelines specifically address asthma in pregnancy and note that stress-dose hydrocortisone is indicated for women on oral steroids ≥7.5 mg daily for ≥2 weeks due to potential HPA axis suppression. 1 This represents widespread practice despite limited direct evidence. 1

For the typical asthma patient NOT on chronic oral steroids undergoing elective cesarean section, no hydrocortisone loading dose is required—simply continue their regular inhaled medications and ensure bronchodilators are available. 1, 2