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Redefining the stress cortisol response to surgery.

Bernard Khoo1, Piers R Boshier2, Alexander Freethy3

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Surgical stress elevates cortisol levels, with peak cortisol correlating positively with surgical severity. This study suggests current dynamic testing criteria for cortisol response may need adjustment and supports stratified steroid replacement dosing for hypoadrenal patients.

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Area of Science:

  • Endocrinology
  • Surgical Physiology

Background:

  • Cortisol levels naturally increase in response to surgical stress.
  • Previous studies on surgical cortisol response used less specific assays and did not account for procedure severity.
  • This study aimed to investigate cortisol response across varying surgical severities using a modern immunoassay.

Purpose of the Study:

  • To examine the relationship between surgical severity and cortisol levels.
  • To assess changes in cortisol-binding globulin (CBG) during surgery.
  • To inform potential adjustments in dynamic cortisol testing and steroid replacement therapy.

Main Methods:

  • Prospective enrollment of 93 euadrenal patients undergoing elective surgery.
  • Serum cortisol and CBG measurements at multiple time points from pre-surgery to 5 days post-op.
  • Classification of surgical severity using the POSSUM operative severity score.

Main Results:

  • Peak cortisol levels showed a positive correlation with surgical severity (Major/Major+ > Moderate > Minor).
  • Cortisol-binding globulin (CBG) decreased by 23%, with the magnitude of decrease also correlating with severity.
  • Observed peak cortisol levels were lower than previously reported.

Conclusions:

  • Surgical stress elicits a wide range of cortisol responses, which are influenced by procedure severity.
  • Modern surgical and anesthetic techniques, along with improved assays, may contribute to lower observed peak cortisol levels.
  • Findings support revising dynamic cortisol testing criteria and adopting a stratified, lower-dose approach for steroid replacement in hypoadrenal patients.