Episodic 24-hour cortisol secretory patterns in patients awaiting elective cardiac surgery

The 24-hour pattern of plasma cortisol concentration in four patients on the day before major elective surgery was compared with that of five similarly hospitalized control subjects to study the effect of the expectation of surgery on the secretion pattern. Using an indwelling venous catheter, which extended outside the patient's room, to collect blood samples every 20 minutes for 24 hours, it was found that cortisol was secreted episodically in both control subjects and presurgical patients. The nychthermal patterns of plasma cortisol concentration in the two groups were indistinguishable for most of the day despite the occurrence of intermittent events which appeared to cause anxiety in the presurgical patients. However, between 9 PM and 11 PM, while each presurgical patient was being preoperatively prepared (body shaving, wash, and enema), a major pulse of cortisol secretion occurred, raising the plasma cortisol concentration to between 6.9-10.5 standard deviations above that of the control subject mean for that time of day. We conclude that 1) expectation of a major surgical procedure for several weeks does not result in chronic activation of the pituitary-adrenocortical axis, 2) many discrete anxiety-provoking events do not evoke cortisol secretory episodes, 3) most episodes of cortisol secretion are part of an endogenous cyclical pattern with a circadian distribution and are not a direct result of environmental stimuli, and 4) preoperative preparation evokes a major cortisol secretory response in patients awaiting surgery. Whether that release of cortisol is a response to the physical manipulations or the psychological implications of that stimulus is presently unknown.