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Activation of the hypothalamic-pituitary-adrenal axis represents one of several important responses to stressful events and critical illnesses. Despite a large volume of published data, several controversies continue to be debated, such as the definition of normal adrenal response, the concept of relative adrenal insufficiency, and the use of glucocorticoids in the setting of critical illness. Stress-dose glucocorticoid administration may be is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. The aim of our study was to assess the cortisol serum levels in males with acute lung abscess or gangrene requiring surgery to determine the accordance of perioperative glucocorticoids. METHODS:The serum levels of cortisol (normal range: 170-720 nmol/L) were measured by radio-immune method in 80 adult males with acute lung abscess (38 cases) or gangrene (42 cases) requiring surgery. The age of the patients was between 29 and 84 (Nf [LQ; UQ] -54.5 [44; 61.5]) years. The duration of the disease at the time of admission to the thoracic surgery department ranged from 1 to 8 (3 [2; 4]) weeks. Pleural empyema was diagnosed in 40 out of 80 (50%) patients, of which 8 cases (20% of all pleural empyema) had pyopneumothorax, systemic inflammatory response syndrome (SIRS)in 43 (54%), sepsis (Sepsis-3)in 16 (20%) cases. RESULTS:Cortisol serum levels was between 83 and 1689 (595 [429; 730]) nmol/L. Cortisol serum levels did not correlate with the age of the patients (r S ¼0.10, p¼0.38) and with disease duration (r S ¼-0.14, p¼0.22). Cortisol serum levels did not differ in patients with abscesses and gangrene (U¼756, r Mann-Whitney ¼0.69), and did not depend on the presence of SIRS, pleural empyema, sepsis, or a combination of both (H¼4.04, p Kruskal-Wallis ¼0.54). The 6 (8%, 95% confidence interval (CI): 2-14) patients had cortisol serum levels below 170 (range at 83 to 145, 94 [89; 100]) nmol/L. The 21 (26%, 95% CI: 16-36) patients had cortisol serum levels above 720 (range at 723 to 1689, 879 [774; 1040]) nmol/L. Cortisol serum levels were within the normal range (at 186 to 718, 526 [429; 633] nmol/L) in 53 (66%, 95% CI: 56-76) patients. CONCLUSIONS:The findings indicate that cortisol serum level varies widely in males with acute lung abscess or gangrene. It does not depend on the age of the patients, the disease duration, the type of disease and complications. Assessment of cortisol serum levels requires laboratory determination. In at least 8% of patients with low cortisol level it possible to use perioperative glucocorticoids to prevent the negative consequences of surgical stress. The effectiveness of this approach needs clinical validation.CLINICAL IMPLICATIONS: The information can be used in justification and development of programs for the perioperative use of glucocorticoids in the surgery of severe lung infections.

Lung abscess and gangrene are complications of viral-bacterial pneumonia. COVID-19 infection can be an initiating factor for its occurrence or to be a background. The aim of our study was to analyze the impact of COVID-19 infection on the development and results of surgical treatment of severe lung infections. METHODS:We compared two groups of patients operated on for lung abscess or gangrene and complications. The 1 st group consisted of patients treated in period from March 2019 to March 2020 (during the year preceding the beginning of COVID-19 in our region). The 2 nd group consisted of patients treated in the period from April 2020 to April 2021 (during an equivalent period of time during COVID-19 in our region). The data of the period from 2015 to 2018 were also used for a comparative assessment. RESULTS:The 1 st group consisted of 19 (86%) males and 3 (14%) females, aged 30 to 68 (Me [LQ; UQ] -56 [40; 61]) years, with acute lung abscess (11 cases, 50%) or gangrene (11 cases, 50%). 2 (33%) patients with lung abscess and 5 (45%) patients with lung gangrene died. The overall mortality rate was 32%. The 2 nd group consisted of 28 (84%) males and 5 (16%) females, aged from 24 to 83 (49 [40; 57]) years, with acute lung abscess (16 cases, 48%) or gangrene (17 cases, 52%). COVID-19 was diagnosed at the onset of the disease in 15 (45%) cases (4 had an active process at the time of surgery). 4 (12%) patients got an illness staying in the department. 3 (40%) patients with lung abscess and 3 (18%) patients with lung gangrene died. The overall mortality rate was 18%. 1 in 14 patients without COVID-19 died. 5 of 19 patients with COVID-19 have died. COVID-19 was diagnosed at the onset of the disease and was active at the time of surgical treatment in 2 died patients. 3 died patients got an illness with COVID-19 staying in the department, while 1 patient got an illness during the period of preparation for discharge after successful treatment of a lung abscess. Mortality did not differ between patients with and without COVID-19 (p Fisher ¼0.21). The overall mortality rate was 18%. Patients of the 1 st and 2 nd groups did not differ in age (U ¼ 295.0; p Mann-Whitney ¼ 0.25), gender (p Fisher ¼ 1.0), frequency of lung abscess and gangrene (p ¼ 0.95), abscess mortality (p Fisher ¼ 1.0) and gangrene mortality (p Fisher ¼ 0.20), overall mortality (c 2 Yates ¼ 0.71; p ¼ 0.40).There were 60 patients operated on for acute lung abscess or gangrene in 2015, 43in 2016, 39in 2017, 32in 2018. The incidence of lung abscess and gangrene requiring surgical treatment was 50% higher during the spread of COVID-19 than in the previous year, but did not exceed the number of observations in the period 2015-2018.CONCLUSIONS: Overall, COVID-19 did not significantly affect the incidence and outcome of surgical treatment of severe lung infections. But active COVID-19 infection aggravates the individual prognosis and the outcome.CLINICAL IMPLICATIONS: Information can be used in the surgery of severe lung infections.DISCLOSURES: no disclosure on file ...

Activation of the hypothalamic-pituitary-adrenal axis represents one of several important responses to stressful events and critical illnesses. Despite a large volume of published data, several controversies continue to be debated, such as the definition of normal adrenal response, the concept of relative adrenal insufficiency, and the use of glucocorticoids in the setting of critical illness. Stress-dose glucocorticoid administration may be is required during the perioperative period because of the possibility of failure of cortisol secretion to cope with the increased cortisol requirement due to surgical stress, adrenal insufficiency, hemodynamic instability, and the possibility of adrenal crisis. The aim of our study was to assess the cortisol serum levels in males with acute lung abscess or gangrene requiring surgery to determine the accordance of perioperative glucocorticoids. METHODS:The serum levels of cortisol (normal range: 170-720 nmol/L) were measured by radio-immune method in 80 adult males with acute lung abscess (38 cases) or gangrene (42 cases) requiring surgery. The age of the patients was between 29 and 84 (Nf [LQ; UQ] -54.5 [44; 61.5]) years. The duration of the disease at the time of admission to the thoracic surgery department ranged from 1 to 8 (3 [2; 4]) weeks. Pleural empyema was diagnosed in 40 out of 80 (50%) patients, of which 8 cases (20% of all pleural empyema) had pyopneumothorax, systemic inflammatory response syndrome (SIRS)in 43 (54%), sepsis (Sepsis-3)in 16 (20%) cases. RESULTS:Cortisol serum levels was between 83 and 1689 (595 [429; 730]) nmol/L. Cortisol serum levels did not correlate with the age of the patients (r S =0.10, p¼0.38) and with disease duration (r S =-0.14, p¼0.22). Cortisol serum levels did not differ in patients with abscesses and gangrene (U¼756, r Mann-Whitney =0.69), and did not depend on the presence of SIRS, pleural empyema, sepsis, or a combination of both (H¼4.04, p Kruskal-Wallis =0.54). The 6 (8%, 95% confidence interval (CI): 2-14) patients had cortisol serum levels below 170 (range at 83 to 145, 526 [429; 633]) nmol/L. The 21 (26%, 95% CI: 16-36) patients had cortisol serum levels above 720 (range at 723 to 1689, 879 [774; 1040]) nmol/L. Cortisol serum levels were within the normal range (at 186 to 718, 526 [429; 633] nmol/L) in 53 (66%, 95% CI: 56-76) patients. CONCLUSIONS:The findings indicate that cortisol serum level varies widely in males with acute lung abscess or gangrene. It does not depend on the age of the patients, the disease duration, the type of disease and complications. Assessment of cortisol serum levels requires laboratory determination. In at least 8% of patients with low cortisol level it possible to use perioperative glucocorticoids to prevent the negative consequences of surgical stress. The effectiveness of this approach needs clinical validation.CLINICAL IMPLICATIONS: The information can be used in justification and development of programs for the perioperative use of glucocorticoids in the surgery of severe lung infections.