Bernard Khoo1, Piers R Boshier2, Alexander Freethy3, George Tharakan3, Samerah Saeed2, Neil Hill3, Emma L Williams4, Krishna Moorthy5, Neil Tolley5, Long R Jiao5, Duncan Spalding5, Fausto Palazzo6, Karim Meeran3, Tricia Tan3. 1. Endocrinology, Division of Medicine, University College London, Royal Free Hospital, London, UK. 2. Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK. 3. Section of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK. 4. Department of Clinical Biochemistry, North West London Pathology, Charing Cross Hospital, London, UK. 5. Department of Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK. 6. Department of Endocrine Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.
Abstract
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 hour, 2 hour, 4 hour and 8 hour after. Subsequent samples were taken daily at 8 am until postoperative 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: Ninety-three 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 = .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 are 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 minimize the deleterious effects of over-replacement.
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 hour, 2 hour, 4 hour and 8 hour after. Subsequent samples were taken daily at 8 am until postoperative 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: Ninety-three 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 = .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 are 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 hypoadrenalpatients, to minimize the deleterious effects of over-replacement.
Authors: Alessandro Prete; Angela E Taylor; Irina Bancos; David J Smith; Mark A Foster; Sibylle Kohler; Violet Fazal-Sanderson; John Komninos; Donna M O'Neil; Dimitra A Vassiliadi; Christopher J Mowatt; Radu Mihai; Joanne L Fallowfield; Djillali Annane; Janet M Lord; Brian G Keevil; John A H Wass; Niki Karavitaki; Wiebke Arlt Journal: J Clin Endocrinol Metab Date: 2020-07-01 Impact factor: 5.958
Authors: Philipp Jansen; Ingo Stoffels; Anne-Christine Müseler; Maximilian Petri; Titus J Brinker; Manfred Schedlowski; Dirk Schadendorf; Harald Engler; Joachim Klode Journal: World J Surg Oncol Date: 2020-03-10 Impact factor: 2.754