Serum cortisol concentration with exploratory cut-off values do not predict the effects of hydrocortisone administration in children with low cardiac output after cardiac surgery

Abstract

OBJECTIVES: Low cardiac output syndrome is common after paediatric cardiac surgery. Previous studies suggested that hydrocortisone administration may improve haemodynamic stability in case of resistant low cardiac output syndrome in critically ill children. This study was set up to test the hypothesis that the effects of hydrocortisone on haemodynamics in children with low cardiac output syndrome depend on the presence of (relative) adrenal insufficiency. METHODS:A retrospective study was done on paediatric patients who received hydrocortisone when diagnosed with resistant low cardiac output syndrome after paediatric cardiac surgery in the period from 1 November 2005 to 31 December 2008. We studied the difference in effects of treatment with hydrocortisone administration between patients with adrenal insufficiency defined as an exploratory cut-off value of total cortisol of <100 nmol/l and patients with a serum total cortisol of ≥100 nmol/l. RESULTS: A total of 62 of patients were enrolled, meeting the inclusion criteria for low cardiac output syndrome. Thirty-two patients were assigned to Group 1 (<100 nmol/l) and 30 were assigned to Group 2 (≥100 nmol/l). Haemodynamics improved after hydrocortisone administration, with an increase in blood pressure, a decrease in administered vasopressors and inotropic drugs, an increase in urine production and a decrease in plasma lactate concentrations. CONCLUSIONS:The effects of treatment with hydrocortisone in children with low cardiac output after cardiac surgery was similar in patients with a low baseline serum cortisol concentration and those with normal baseline cortisol levels. A cortisol value using an exploratory cut-off value of 100 nmol/l for adrenal insufficiency should not be used as a criterion to treat these patients with hydrocortisone.

Stress-Dose Corticosteroid Versus Placebo in Neonatal Cardiac Operations: A Randomized Controlled Trial

“…Open heart operations and CPB itself did not cause a major depression in the postoperative plasma cortisol levels in the neonates receiving placebo in contrast to previous reports [8,9,[11][12][13][14]. Rather, the postoperative low serum cortisol levels observed in the previous studies were possibly iatrogenic in origin owing to the high doses of corticosteroids administered preoperatively or intraoperatively [8,9,[11][12][13][14].…”

“…This shows that the optimal serum cortisol levels are unknown, especially in neonates, and that the definition of AI is somewhat arbitrary because of a paucity of data on steroid metabolism [10,13,14]. Therefore, postoperative corticosteroid treatment in children undergoing cardiac operations should not be solely based on their plasma cortisol levels [11,12]. The clinical presentation of AI; tachycardia and hypotension resistant to fluid and inotrope therapy are also common presentations for a wide spectrum of critically ill children [20].…”

“…Placebo-controlled observations on the potential benefits of prophylactic postoperative "stress dosing" by hydrocortisone infusion in neonates undergoing cardiac operations include a reduction of the inflammatory response and the lower incidence of low cardiac output syndrome, improved fluid balance, and prevention of adrenal insufficiency (AI) [8,9]. However, knowledge is lacking about the appropriate plasma cortisol level after cardiac operations and its effect on the postoperative outcome [10][11][12][13][14].…”

Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit

“…The use of basal cortisol, CSS testing, or glucocorticoids in patients with fluid- and catecholamine-resistant septic shock and low cardiac output after cardiac surgery for congenital heart disease remains controversial [4-7]. The results of the testing and the response to corticosteroids in these patients may merely reflect the severity of disease rather than the presence of RAI.…”

Steroids in paediatric heart surgery: eminence or evidence-based practice?

“…Therefore, such frequent variations in the cortisol concentration make the ACTH tests inaccurate because they rely on a just few time-point measurements that can be taken either at the peak or trough of the pulse [40]. Several studies tried to assess the HPA axis during surgery [41][42][43][44][45][46][47][48][49][50][51]. Some used a few time cortisol measurements or just ACTH stimulation tests and tried to correlate their findings with clinical outcomes.…”