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The effect of cardiopulmonary bypass on the hypothalamic-pituitary-adrenal axis in children

Eric L Wald1, Elizabeth Preze, Jens C Eickhoff

  • 1Department of Surgery, Northwestern University Medical School, Children's Memorial Hospital, Chicago, IL, USA. ewaldchildrensmemorial.org

Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
|September 15, 2010
PubMed

Insights

Low cardiac output syndrome in pediatric heart surgery patients may involve adrenal insufficiency. Decreased corticosteroid-binding globulin and increased free cortisol post-surgery correlate with poorer clinical outcomes, suggesting complex adrenal axis involvement.

Area of Science:

  • Pediatric Cardiology
  • Endocrinology
  • Critical Care Medicine

Background:

  • Low-cardiac-output syndrome (LCOS) is a significant complication following cardiopulmonary bypass (CPB) in pediatric heart surgery.
  • The role of adrenal insufficiency in the pathophysiology of LCOS after CPB remains incompletely understood.
  • Assessing hypothalamic-pituitary-adrenal (HPA) axis function, particularly adrenal responsiveness, is crucial for understanding LCOS.

Purpose of the Study:

  • To investigate the impact of CPB on the HPA axis and adrenal responsiveness in pediatric patients with congenital heart disease.
  • To correlate postoperative bound and free cortisol levels, along with corticosteroid-binding globulin (CBG) levels, with clinical outcomes.
  • To determine if these hormonal variables serve as sensitive indicators of adrenal axis function in this patient population.

Main Methods:

  • A prospective cohort study was conducted involving 52 pediatric patients undergoing heart surgery with CPB.
  • Total cortisol and CBG levels were measured preoperatively and postoperatively.
  • A postoperative cosyntropin stimulation test was performed, with free cortisol calculated using Coolens' method.

Main Results:

  • 17.6% of patients exhibited low baseline postoperative total cortisol, yet all showed normal responses to stimulation.
  • CBG levels significantly decreased postoperatively (mean 29 to 22 mg/L, p < .001) with considerable inter-patient variability.
  • Elevated free cortisol increase post-stimulation (δ >6 μg/dL) was associated with longer hospital stay, higher inotrope scores, increased fluid requirements, and prolonged mechanical ventilation.

Conclusions:

  • HPA axis dysfunction may contribute to LCOS in pediatric congenital heart surgery, but total cortisol measurements alone may be insufficient.
  • Reduced CBG levels and a significant increase in free cortisol post-stimulation are linked to adverse clinical outcomes.
  • Further research is needed to explore the cortisol-CBG complex and its relationship with free cortisol for a comprehensive understanding of adrenal insufficiency.
Abstract

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