The inflammatory response to cardiac surgery with cardiopulmonary bypass: should steroid prophylaxis be routine?

Cardiac surgery with cardiopulmonary bypass (CPB) triggers a vigorous systemic inflammatory response characterized by early and late phases involving both the humoral and cellular pathways. Steroids dampen the immune response to CPB in a multimodal fashion. Perioperative steroid prophylaxis offers the possibility to manipulate the inflammatory response to CPB for outcome benefit. In adult cardiac surgery with CPB, steroids have been rigorously evaluated in multiple randomized clinical trials and meta-analyses. In summary, steroid therapy in this setting can significantly reduce perioperative morbidity. Although the outcome benefits of steroids in adult cardiac surgery with CPB are apparent, multicenter large randomized trials are in progress to determine whether these agents should become a routine component of an anti-inflammatory approach to optimize clinical outcome. The current application of steroids in adult CPB is highly variable, with the highest use likely in high-risk settings such as deep hypothermic circulatory arrest. In pediatric cardiac surgery with CPB, steroids are widely used despite a limited evidence base compared with adult CPB. Recent multicenter observational trials have paved the way for larger more definitive randomized trials targeted to high-risk pediatric CPB including the neonatal period. In conclusion, steroids offer significant potential to improve meaningful clinical outcomes after cardiac surgery with CPB. The results of 2 landmark multicenter randomized trials in adult CPB likely will determine whether steroids should become routine therapy in this setting. It is likely that similar multicenter trials in pediatric CPB will be launched in the near future.