Postoperative Serum Cortisol Concentration and Adrenal Insufficiency in Neonates Undergoing Open-Heart Surgery

Abstract

Low cortisol obtained in the immediate postoperative period is not associated with worse postoperative outcomes or predictive of steroid responsiveness. In contrast, elevated levels of cortisol are positively correlated with severity of illness. The use of an absolute cortisol threshold to identify adrenal insufficiency and/or guide steroid therapy in neonates after cardiac surgery is unjustified.

Clinical significance of serum cortisol levels following surgery for congenital heart disease

“…To our knowledge, this report is the first study to find a relationship between total serum cortisol concentration and clinical response to hydrocortisone in children recovering from cardiac surgery. Contrary to our study hypothesis and previous reports, [6][7][8] we found that patients who had a favourable haemodynamic response to hydrocortisone therapy were more likely to have lower total serum cortisol concentrations as compared with those who did not respond. In addition, our proportion of favourable responders (58%) was higher than what has been reported previously.…”

“…1,2 Several studies have described the use of systemic corticosteroid therapy with hydrocortisone to decrease the effects of postoperative low cardiac output syndrome and improve haemodynamic integrity in many of these patients. [3][4][5][6][7][8] These haemodynamic benefits do not appear to be universal but rather have been observed in~40% of patients in whom it is administered. [6][7][8] Some centres including our institution often obtain random total serum cortisol concentrations to guide hydrocortisone therapy, based on the assumption that patients with low serum cortisol concentrations may be more likely to benefit from this therapy.…”

“…[3][4][5][6][7][8] These haemodynamic benefits do not appear to be universal but rather have been observed in~40% of patients in whom it is administered. [6][7][8] Some centres including our institution often obtain random total serum cortisol concentrations to guide hydrocortisone therapy, based on the assumption that patients with low serum cortisol concentrations may be more likely to benefit from this therapy. Studies to date, however, have not supported this practice, although the definition of what constitutes haemodynamic benefit has varied between these reports.…”

“…Studies to date, however, have not supported this practice, although the definition of what constitutes haemodynamic benefit has varied between these reports. [6][7][8] The significance of random total serum cortisol concentrations therefore remains unclear, and there are currently no clear guidelines for the implementation of hydrocortisone therapy in this patient population.…”

Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

“…Postoperative baseline serum cortisol did not correlate with the presence of AI, nor was cortisol associated with any of the clinical outcomes, similar to what is reported in many pediatric CPB studies. In contrast, a few investigators have found high serum cortisol level to be associated with surrogates of low cardiac output and increased severity of illness (15). Of note, our median prestimulation cortisol level in the OR was very high (75 lgÁdl À1 ) relative to cortisol levels reported in other studies after pediatric CPB.…”