Changes in the pituitary-adrenal system for extracorporal membrane oxygenation: prospective study

Abstract

INTRODUCTION. At the moment, assessing adrenal dysfunction in patients in critical condition and ways to correct this function with hormone replacement therapy are extremely difficult. OBJECTIVE. Analysis of changes in the dynamics of adrenocorticotropic hormone (ACTH) and cortisol levels in blood plasma during extracorporeal membrane oxygenation (ECMO). MATERIALS AND METHODS. The prospective study was performed in intensive care unit (47 patients on ECMO). After connecting ECMO (D0), (D1-D3-D5-D7-D9), and until the completion of ECMO, assessment of cortisol and ACTH levels was carried out. RESULTS. The median level of cortisol in blood plasma was higher in the deceased patients on the third day (D3) (p = 0.05), D7 (p = 0.03); D13 (p = 0.05) and the last day of observation (p = 0.001), respectively. The level of ACTH in the blood of deceased patients was higher immediately on the day of ECMO initiation (D0) and on day 3 (D3) of observation: D0 (p = 0.018); D3 (p = 0.04), respectively. Analysis of the ROC curve showed that cortisol levels show a sensitivity of 71 % and a specificity of 89 % to an adverse outcome during ECMO. DISCUSSION. The life-saving ECMO technique, in critical conditions, is associated with a high risk of increasing of complications, including potentially lethal ones. Critical illness-related corticosteroid insufficiency (CIRCI) clinically manifests itself as inadequate adrenal activity, taking into account the augmentation of the disease severity. This activity is expressed in the form of a decrease in production and/or resistance to endogenous cortisol, as confirmed by the study. Consideration of CIRCI during the usage of ECMO reflects more objectively the violation of the pituitary-adrenal system. CONCLUSIONS. 1. CIRCI is detected in patients during ECMO. 2. High plasma cortisol levels are the predictor of an adverse outcome. 3. The level of ACTH in blood plasma is higher in patients with adverse outcomes. 4. High levels of cortisol in plasma are not a criterion for making the decision to initiate hydrocortisone therapy.

Profiling endogenous adrenal function during veno-venous ECMO support in COVID-19 ARDS: a descriptive analysis

“…Presently, there is only limited information about the direct impact of ECMO on HPA axis signalling. In a setting of low-dose GC treatment and alternative veno-venous-to veno-arterial ECMO support, Altshuler et al reported higher cortisol and ACTH levels in deceased patients compared to survivors (7), and pre-ECMO conditions were investigated from Agus et Jaksic, which showed low cortisol and aldosterone values in a small collective of ECLS primed circuits of infants (33). As a drastic measure of organ replacement, ECMO acts as a stressor via haemodynamic changes, inflammatory and coagulopathic effects due to cannulation, predisposition to infection, or bleeding complications (7,18).…”

“…Since HPA-axis-perturbing hypoxia and inflammation are considered causes of CIRCI ( 5 ), the investigation of adrenal function in the setting of ECMO due to respiratory failure seems imperative. Recent studies reported the occurrence of CIRCI in patients during ECMO support ( 6 , 7 ). However, due to different underlying causes of ARDS and the requirement of HPA axis-affecting medication like glucocorticoids, an accurate and consecutive assessment of adrenal function over time remains challenging.…”