The Cortisol Serum Levels in Patients With Severe Lung Infections Requiring Surgery

Abstract

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.