Measurement of Serum Free Cortisol Shows Discordant Responsivity to Stress and Dynamic Evaluation (original) (raw)
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Cortisol and antidiuretic hormone responses to stress in cardiac surgical patients
Canadian Anaesthetists’ Society Journal, 1981
The hormonal responses to anaesthesia and cardiac surgery were studied in patients undergoing valve or coronary bypass surgery. Marked increases in antidiuretic hormone levels as a result of surgical stress were seen, and were of approximately equal magnitude in both groups. Although both groups also showed marked increases in plasma cortisol levels in response to operations, this response appeared to be relatively bhmted in valve surgery patients, especially at the end of operation and in the intensive care unit. This blunted cortisol response may be a manifestation of exhaustion of adrenocortical reserves in valvular surgical patients whose sympathoadrenal system has already been chronically stimulatcd by a low output state.
Redefining the stress cortisol response to surgery
Clinical Endocrinology
Background Cortisol levels rise with the physiological stress of surgery. Previous studies have used older, less-specific assays, have not differentiated by severity, or only studied procedures of a defined type. The aim of this study was to examine this phenomenon in surgeries of varying severity using a widely used cortisol immunoassay. Methods Euadrenal patients undergoing elective surgery were enrolled prospectively. Serum samples were taken at 8 am on surgical day, induction and 1 hr, 2 hr, 4 hr and 8 hr after. Subsequent samples were taken daily at 8 am until post-operative day 5 or hospital discharge. Total cortisol was measured using an Abbott Architect immunoassay, and cortisol binding globulin (CBG) using a radioimmunoassay. Surgical severity was classified by POSSUM operative severity score. Results 93 patients underwent surgery: Major/Major+ (n=37), Moderate (n=33), and Minor (n=23). Peak cortisol positively correlated to severity: Major/Major+ median 680 [range 375-1452], Moderate 581 [270-1009], and Minor 574 [272-1066] nmol/L (Kruskal-Wallis test, P=0.0031). CBG fell by 23%; the magnitude of the drop positively correlated to severity. Conclusions The range in baseline and peak cortisol response to surgery is wide, and peak cortisol levels lower than previously appreciated. Improvements in surgery, anaesthetic techniques, and cortisol assays might explain our observed lower peak cortisols. The criteria for the dynamic testing of cortisol response may need to be reduced to take account of these factors. Our data also support a lower-dose, stratified approach to dosing of steroid replacement in hypoadrenal patients, to minimise the deleterious effects of over-replacement.
Journal of Bangladesh Society of Physiologist, 2008
The study was designed to observe the effects of surgical stress on serum level of cortisol in patients undergoing surgical treatment and to find out any differences in hormonal response between elective and emergency surgical procedures. A total number of 60 male subjects aged between 18 and 45 years were included in the study. Of them, 20 were healthy control (Group I), 20 underwent elective surgical treatment (Group II) and emergency surgical interventions were applied in rest 20 subjects (Group III). Study Groups were further divided into subgroups A (preoperative samples were collected 1- hour before operation), B (postoperative samples were collected 1-hour after the end of the operation) and C (postoperative samples were collected 24-hours after operation).Serum cortisol level was estimated by invitro-immunolytic test.Statistical analysis was done by paired, unpaired ‘t' test and regression analysis. The preoperative mean serum cortisol concentration in elective surgical ...
Polish Journal of Cardio-Thoracic Surgery
Introduction: Cortisol level affects the prognosis of patients after cardiac surgery. Meanwhile, there are no clear guidelines for steroid supplementation after a cardiac operation. The relationship between age and blood cortisol levels has not been finally clarified. Aim: Assessment of adrenal reserve and secretion of cortisol in patients over 60 years of age undergoing cardiac surgery. Material and methods: The study included 20 patients of both sexes referred for cardiac surgery. A short ACTH synthetic stimulation test was carried out. Assessment of cortisol secretion was carried out in the morning on the day of surgery and the 1 st , 2 nd and 4 th days after surgery in blood samples. Results: A result within the normal range for the adrenal reserve was found in 19 of the 20 patients enrolled in the study. The short Synacthen test predicted postoperative secretion of cortisol (p = 0.04, r = 0.047). A relationship between secretion of cortisol and patients' age was observed (p = 0.03, r = 0.48). The concentration of cortisol on the 1 st postoperative day was correlated with the total dose of dopamine (p = 0.006, r = 0.58) and adrenaline (p = 0.04, r = 0.47). The concentration of cortisol on the day of the surgery correlated with the lactate concentration on day 2 (p = 0.04, r = 0.45). The concentration of lactates on day 1 correlated with total dose of dopamine (p = 0.01, r = 0.54). Conclusions: A short Synacthen test allows one to predict secretion of cortisol after cardiac surgery. Greater secretion of cortisol after cardiac surgery may be associated with a more difficult postoperative course. There was no decrease in cortisol secretion with age.
Steroids, 2000
Previous studies have demonstrated a persistent rise in serum cortisol concentrations after cardiac surgery. To further investigate this finding and to evaluate the effect of hemodilution that occurs with the onset of cardiopulmonary bypass (CPB), concentrations of cortisol-binding globulin (CBG), total and unbound cortisol, and packed cell volume (PCV) were studied in 28 patients undergoing coronary artery bypass graft surgery. All patients received a standardized general anesthetic using a balanced technique with sufentanil, isoflurane, and midazolam. Blood was collected preoperatively, intraoperatively during CPB, and postoperatively in the evenings on the day of surgery and on the first and second postoperative day. Cortisol and CBG concentrations were measured by radioimmunoassay and were used to calculate the fraction of unbound cortisol. Serum CBG and cortisol concentrations corrected for hemodilution were significantly higher than non-corrected values. Perioperatively, CBG measurements were significantly intercorrelated. Intraoperatively, total and unbound cortisol concentrations were not significantly increased compared to preoperative values. Postoperatively up to the end of the study period serum concentrations of total and unbound cortisol were significantly increased compared to baseline values. Our results suggest that hemodilution occurs in all patients during cardiac surgery and continues up to the second postoperative day. This may lead to an underestimation of serum cortisol and CBG concentrations in patients undergoing heart surgery with CPB. Intraoperatively, concentrations of total and unbound cortisol were not significantly elevated. The postoperative rise in serum total cortisol concentration was accompanied by an increase in unbound cortisol concentration. The postoperative increase of unbound cortisol concentrations in patients undergoing cardiac surgery with CPB was largely due to an increase in cortisol secretion.
Cortisol Response to Operative Stress With Anesthesia in Healthy Children
The Journal of Clinical Endocrinology & Metabolism, 2013
Background: Supraphysiological "stress dosing" is generally given to adrenally insufficient patients undergoing operative procedures and/or general anesthesia. However, the normal responses of cortisol to surgery are poorly documented, especially in small children. Recent studies in adults suggest that massive glucocorticoid dosing is not needed, especially in minimally invasive surgery. Objective: We sought to characterize the normal cortisol secretion rate in healthy children undergoing minimally and moderately invasive urological procedures. Design and Setting: This was a prospective observational study conducted at a tertiary referral center. Patients: Thirty healthy children, ages 5 months to 6 years, were studied undergoing elective urological procedures. Methods: Procedures were performed by a single surgeon; anesthesia was by a standard protocol. Sera were obtained at 5 points: iv catheter placement, intubation, 50% completion of surgery, anesthesia reversal, and 1 hour postoperative. Cortisol and cortisone were quantitated by liquid chromatography-tandem mass spectrometry. Results: Group mean cortisol values ranged from 4.21 to 5.71 g/dL across the 5 time points; none of these mean values differed significantly (P Ͻ .05). There were no differences according to age, time of procedure, caudal anesthesia, and moderate vs minimally invasive procedures; 3 patients had higher values. There was a modest diminution in cortisone across the 5 time points. Conclusions: Minimal and moderately invasive urological procedures do not result in a cortisol stress response in healthy children. Peak cortisol levels were seen 1 hour postoperatively. These data suggest that current guidelines for stress dosing in adrenally insufficient patients substantially exceed physiological requirements during minimally invasive procedures. (J Clin Endocrinol Metab 98: 3687-3693, 2013) E arly studies of adrenal function and steroidogenesis led to a general understanding of adrenally insufficient states (1, 2). In the 1950s, patients were reported with lethal intraoperative circulatory shock after withdrawal from pharmacological glucocorticoid therapy before surgery (3, 4). Postmortem examination of 1 patient revealed diffuse atrophy and hemorrhage in the adrenal; the cause of death was listed as adrenal insufficiency. Guidelines were developed to prevent such future occurrences in patients with both primary and secondary adrenal insufficiency. Recommendations were generalized to quadruple a patient's current glucocorticoid dose in the perioperative period to cover the "stress" of procedures and anesthesia (4). In the decades following
The cortisol stress response induced by surgery: A systematic review and meta-analysis
Clinical endocrinology, 2018
Surgery is a stressor that can be categorized by duration and severity and induces a systemic stress response that includes increased adrenal cortisol production. However, the precise impact of surgical stress on the cortisol response remains to be defined. We performed a systematic review and meta-analysis to assess the cortisol stress response induced by surgery and to stratify this response according to different parameters. We conducted a comprehensive search in several databases from 1990 to 2016. Pairs of reviewers independently selected studies, extracted data and evaluated the risk of bias. Cortisol concentrations were standardized, pooled in meta-analysis and plotted over time. We included 71 studies reporting peri-operative serum cortisol measurements in 2953 patients. The cortisol response differed substantially between moderately/highly invasive and minimally invasive surgical procedures. Minimally invasive procedures did not show a peri-operative cortisol peak, whereas ...
Medical Science Monitor, 2018
Departmental sources Background: A recent study reported that patients with higher cortisol levels on the 1 st postoperative morning after cardiac surgery exhibited an increased risk of early postoperative cognitive decline (POCD). Therefore, we conducted the current study to gain further insight into the stress response to a surgical procedure as a potential risk factor for early POCD after cardiac surgery. Material/Methods: This prospective cohort study enrolled 125 patients undergoing elective cardiac surgery with or without cardiopulmonary bypass (CPB). Patient serum cortisol levels were determined 1 day before surgery (at 08: 00) and on the 1 st (at 08: 00, 16: 00 and 24: 00), 3 rd (at 08: 00), and 5 th (at 08: 00) postoperative days. A battery of 9 neuropsychological tests were used to assess the participants 2 days before the surgical procedure and on the 6 th postoperative day. POCD was defined as a decrease in performance of 1 SD or greater between the postoperative and preoperative z scores on at least 1 neuropsychological test. A mixed-design ANOVA was used to determine the correlations of the perioperative cortisol levels with the occurrence of POCD and with the surgical technique performed. Results: Mixed-design ANOVA showed no statistically significant differences in the cortisol levels between non-POCD and POCD patients (F=0.52, P=0.690) or between patients with and without CPB (F=2.02, P=0.103) at the 6 perioperative time points. Conclusions: The occurrence of early POCD and the use of CPB were not associated with significantly higher cortisol levels in the repeated measurement design.
Acute Stress Assessment From Excess Cortisol Secretion: Fundamentals and Perspectives
Frontiers in Endocrinology
Our paper aims to redefine the concept of stress in the context of maintaining allostasis; the term has been reserved for situations that concomitantly involve established physiological and psychological stress components. In particular, we analyze how novelty, unpredictability, threat to the ego, and low sense of control challenge allostasis. The concept of stress is then related to a state of difficulty in maintaining allostasis, rather than referring to the overall body response to the situation. This state of difficulty may be observed either in planning the strategy to deal with the situation, evaluating consequent target trajectories for the actuators, the catabolic mediators and the activators, or regulation of the biological systems through these trajectories. Catabolic mediator excesses are proposed as scaling the level of difficulty in maintaining allostasis. The excess proportion of cortisol load (EPCL) is consequently proposed to scale the stress level. A first proof-of-concept of this indicator is realized using the Physiostress dataset, by asserting that it is, as predicted from its theoretical basis, more in phase with the stress level expected from the nature of the task and participant-reported stress compared to common indicators based on the cortisol response magnitude itself.