Eric L Wald1, Carl L Backer2, Joseph A Dearani3, Zhuo Li4, William C Oliver5, Sheri S Crow6. 1. Divisions of Critical Care and Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill. Electronic address: Ewald@luriechildrens.org. 2. Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill. 3. Division of Cardiothoracic Surgery, Mayo Clinic, Rochester, Minn. 4. Division of Statistics, Mayo Clinic, Rochester, Minn. 5. Department of Anesthesiology, Mayo Clinic, Rochester, Minn. 6. Division of Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minn.
Abstract
BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery. METHODS: We enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-μg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness. RESULTS: Sixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (<9 μg/dL) at TP2 had greater fluid requirements (P < .001) and greater chest tube output (P < .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3. CONCLUSIONS: We observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ <9 μg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.
BACKGROUND:Hypothalamic-pituitary-adrenal (HPA) axis dysfunction may be partially responsible for the hemodynamic instability experienced by infants after cardiopulmonary bypass (CPB). We report the full spectrum of the HPA response surrounding CPB for infant congenital cardiac surgery. METHODS: We enrolled 84 infants who received 1 mg/kg of dexamethasone before initiation of CPB. Total cortisol (TC), free cortisol (FC), adrenocorticotropic hormone (ACTH), and corticosteroid-binding globulin (CBG) were measured at 3 time points: immediately before CPB (TP1), on intensive care unit arrival (TP2), and at 24 hours after surgery (TP3). A 1-μg ACTH stimulation test was performed at each time point to evaluate adrenal responsiveness. RESULTS: Sixty-eight infants completed all study procedures. Levels of TC, FC, CBG, and ACTH decreased significantly between the preoperative and 24-hour postoperative measurements. There were no significant associations between preoperative FC responses and clinical outcomes after adjusting for weight and Risk-Adjusted Scores for Congenital Heart Surgery. Infants with subnormal TC responses to ACTH stimulation (<9 μg/dL) at TP2 had greater fluid requirements (P < .001) and greater chest tube output (P < .001) during the first 24 hours, as well as longer length of stay (LOS) (P = .007). Except for LOS, these differences persisted for infants with subnormal stimulation tests at TP3. CONCLUSIONS: We observed a significant decline in all aspects of the HPA axis throughout the first 24 hours after infant CPB. TC and FC levels were not associated with clinical outcomes. Subnormal (Δ <9 μg/dL) TC response to cosyntropin stimulation during the postoperative period was associated with increased fluid resuscitation and greater LOS.
Authors: Saul Flores; David S Cooper; Amy M Opoka; Ilias Iliopoulos; Sarah Pluckebaum; Matthew N Alder; Kelli A Krallman; Rashmi D Sahay; Lin Fei; Hector R Wong Journal: Pediatr Crit Care Med Date: 2018-08 Impact factor: 3.624
Authors: Amy J Lisanti; Abigail C Demianczyk; Andrew Costarino; Maria G Vogiatzi; Rebecca Hoffman; Ryan Quinn; Jesse L Chittams; Barbara Medoff-Cooper Journal: Pediatr Crit Care Med Date: 2020-09 Impact factor: 3.624