Document Detail

The effect of cardiopulmonary bypass on the hypothalamic-pituitary-adrenal axis in children.
MedLine Citation:
PMID:  20838356     Owner:  NLM     Status:  In-Data-Review    
OBJECTIVE: : The pathophysiology of low-cardiac-output syndrome after cardiopulmonary bypass is incompletely understood, but adrenal insufficiency has been proposed as a contributing factor. Our objective was to examine the effect of cardiopulmonary bypass on the hypothalamic-pituitary-adrenal axis, specifically adrenal responsiveness, in patients with congenital heart disease undergoing surgery. We hoped to correlate bound and free cortisol values both postoperatively and after adrenocorticotropic hormone stimulation, in conjunction with corticosteroid-binding globulin levels, with clinical outcomes to determine whether these variables are sensitive indicators of adrenal axis function.
DESIGN: : Prospective cohort study.
SETTING: : A children's hospital.
PATIENTS: : Fifty-two pediatric heart surgery patients undergoing cardiopulmonary bypass.
INTERVENTION: : Total cortisol and corticosteroid-binding globulin levels were obtained pre- and postoperatively and after a postoperative cosyntropin stimulation test. Free cortisol was calculated by using Coolens' method.
MEASUREMENTS AND MAIN RESULTS: : Nine of 51 (17.6%) patients had low (<3 μg/dL) baseline postoperative total cortisol, median 1.6 μg/dL, yet all nine had normal (>9 μg/dL increase from postoperative baseline) stimulation tests. The corticosteroid-binding globulin levels declined from a mean of 29 mg/L preoperatively to 22 mg/L postoperatively (p < .001) and showed marked variability between patients. Patients with free cortisol δ >6 μg/dL (n = 18, 35%) had a longer length of stay (median 9 vs. 5 days; p = .002), higher inotrope scores (median 13.3 vs. 10.8; p = .05), greater fluid requirement (median 73.5 vs. 55.6 mL/kg; p = .007), and longer ventilator times (median 41.5 vs. 20 hrs; p = .013).
CONCLUSIONS: : Although hypothalamic-pituitary-adrenal axis dysfunction may play a role in low-cardiac-output syndrome among children undergoing congenital heart surgery, using total cortisol to investigate such dysfunction may be inadequate. Decreased corticosteroid-binding globulin levels and marked free cortisol increase after stimulation were associated with worse clinical outcomes. Further investigation into the cortisol-corticosteroid-binding globulin complex and its relationship to free cortisol is necessary to examine the problem of adrenal insufficiency from a more integrated perspective.
Eric L Wald; Elizabeth Preze; Jens C Eickhoff; Carl L Backer
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies     Volume:  12     ISSN:  1529-7535     ISO Abbreviation:  Pediatr Crit Care Med     Publication Date:  2011 Mar 
Date Detail:
Created Date:  2011-06-07     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  100954653     Medline TA:  Pediatr Crit Care Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  190-6     Citation Subset:  IM    
From the Departments of Surgery (CLB, EP) and Pediatrics (ELW), Northwestern University Medical School, Divisions of Cardiovascular-Thoracic Surgery and Pediatric Critical Care Medicine (CLB), Children's Memorial Hospital, Chicago, IL; Department of Biostatistics (JCE), University of Wisconsin School of Medicine and Public Health, Madison, WI.
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