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Adrenocortical response in infants undergoing cardiac surgery with cardiopulmonary bypass and circulatory arrest
Robert J Gajarski1, Christopher B Stefanelli, Joseph N Graziano
1Department of Pediatrics, Division of Cardiology, University of Michigan Health Center, Ann Arbor, MI, USA. rjgaj@med.umich.edu
Insights
Infants undergoing cardiac surgery generally show normal adrenal response. However, some may experience adrenal insufficiency, indicated by elevated ACTH/cortisol ratios, potentially benefiting from early steroid therapy.
Area of Science:
- Pediatric Cardiology
- Endocrinology
- Critical Care Medicine
Background:
- Cardiac surgery in infants can impact the hypothalamic-pituitary-adrenal (HPA) axis.
- Adrenal insufficiency is a concern in critically ill pediatric patients post-cardiac surgery.
Purpose of the Study:
- To assess adrenocorticotropic hormone (ACTH), cortisol, and aldosterone levels after pediatric cardiac surgery.
- To investigate if infants needing high-dose vasopressors exhibit adrenal insufficiency proportional to cardiopulmonary bypass (CPB) or circulatory arrest times.
Main Methods:
- Prospective observational pilot study in a pediatric cardiac intensive care unit.
- Infants were categorized into cardiopulmonary bypass (CPB), deep hypothermic circulatory arrest (DHCA), and control groups.
- Serum samples for cortisol and ACTH were collected post-surgery; ACTH stimulation tests were performed preoperatively.
Main Results:
- Preoperative adrenal function was normal in tested infants.
- Cortisol levels peaked within 2 hours post-surgery, with no significant differences between groups.
- ACTH inversely correlated with bypass time in DHCA patients (p=.03); peak cortisol did not correlate with inotrope score.
- Nine patients showed elevated ACTH/cortisol ratios, suggesting inadequate adrenal response.
Conclusions:
- Most infants with congenital heart disease have an appropriate adrenocortical stress response to cardiac surgery.
- Peak cortisol levels did not correlate with CPB/DHCA duration or inotrope support.
- A subset of patients with high ACTH/cortisol ratios may have adrenal insufficiency and could benefit from early steroid treatment.
Objective:
To detail changes in adrenocorticotropic hormone (ACTH), cortisol, and aldosterone levels following cardiac surgery and to test the hypothesis that postcardiotomy infants requiring excessively high-dose vasopressor support will demonstrate adrenal insufficiency which will be proportional to cardiopulmonary bypass (CPB)/circulatory arrest times and vasopressor requirements.
Design:
Prospective observational pilot study.
Setting:
A tertiary care pediatric cardiac intensive care unit.
Patients:
Prospectively enrolled infants were divided into three subgroups: CPB, CPB with deep hypothermic circulatory arrest (DHCA), and control subjects.
Interventions:
None.
Measurements And Main Results:
A representative patient sample from each surgical group underwent preoperative synthetic ACTH testing. Postoperative serum samples for cortisol, ACTH, and inotrope score (IS) were collected at discrete intervals over 48 hrs along with patient demographics, surgical procedure, and CPB/DHCA times. Fifty-eight patients were classified by subgroup: 31 CPB, 22 DHCA, and 5 controls. Ten patients with DHCA, analyzed separately, received intraoperative steroids. Tested patients demonstrated preoperative adrenal competence. Cortisol peaked within 2 hrs of surgery without differences among groups. ACTH inversely correlated with bypass time in patients with DHCA (p = .03) but not with circulatory arrest time. Peak cortisol level did not correlate with simultaneous IS. Although not noted in any DHCA-steroid patients, nine patients had increased ACTH/cortisol ratios in association with elevated ISs suggesting inadequate adrenal responsiveness to endogenous ACTH.
Conclusions:
The majority of infants with congenital heart disease and intact hypothalamic-pituitary-adrenal axes demonstrated an appropriate adrenocortical stress response to cardiac surgery. Peak serum cortisol was unrelated to CPB/DHCA time and did not predict the level of inotrope support. However, a subset of patients with elevated ACTH/cortisol ratios seemed to have a clinical status consistent with adrenal insufficiency and may be a target group for early postoperative steroid therapy.
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