Searchable abstracts of presentations at key conferences in endocrinology
Endocrine Abstracts (2010) 21 P352

SFEBES2009 Poster Presentations Steroids (37 abstracts)

Assessing adrenal status in patients before and after coronary artery bypass graft surgery

Miguel Debono 1 , Lorcan Sheppard 2 , Sarah Irving 2 , Zoe Brookes 2 , John Newell-Price 1 , John Ross 2 & Richard Ross 1


1Academic Unit of Endocrinology, University of Sheffield, Sheffield, UK; 2Cardiothoracic Unit, Northern General Hospital, Sheffield, UK.


Background: Cortisol is an essential stress hormone and deficient patients suffering a systemic inflammatory response (SIR) will rapidly die if not replaced. However, controversy remains on the definition for a normal adrenal response in critically ill patients. We investigated cortisol status in patients undergoing coronary artery bypass surgery (CABG), surgery frequently associated with a SIR, varying in severity from sub-clinical, to life-threatening.

Methods: A prospective study was performed to analyse tests for adrenal insufficiency pre- and post-operatively. Prior to CABG 30 patients had a basal ACTH and a short Synacthen test (250 μg, i.v). After being weaned off cardiopulmonary bypass, patients were transferred to CICU, and had a post-op ACTH and Synacthen test around 4 h from time of induction. A 30 min cortisol post-Synacthen <550 nmol/l was taken as an abnormal response. Intensive care monitoring parameters were recorded.

Mean (95% CI)Pre-opPost-opP value
Basal cortisol (nmol/l)447 (385–509)501 (393–609)0.4
Peak cortisol post-Synacthen (nmol/l) 1048 (945–1151)730 (632–828)<0.001
Δ – cortisol post-Synacthen (nmol/l)579 (504–654)229 (170–288)< 0.001
% Change in cortisol (100% * peak-basal cortisol/basal cortisol)161 (112–210)77 (45–107)0.002
ACTH (ng/l)21 (16–26)184 (72–296)0.007
Cortisol/ACTH ratio24 (21–27)9 (6–12)<0.001

Results: Prior to surgery all patients had a normal response to Synacthen with a peak cortisol >550 nmol/l. In contrast, post-op, eight patients (26.7%) did not obtain stimulated-cortisol levels >550 nmol/l. 11/22 in those with a response to Synacthen >550 nmol/l and 5/8 in those with a response <550 nmol/l needed inotropes with a significant difference in time on inotropes (8.4 vs 21.0 h; P=0.05) and time to extubation (5.6 vs 11.7 h; P<0.001). Notwithstanding, all patients had a good final outcome from surgery.

Interpretation: The results show that up to a quarter of patients with a normal pre-operative ACTH and cortisol response to Synacthen show a raised ACTH and apparent deficient cortisol response post-operatively. In conclusion, caution needs to be taken interpreting endocrine tests post major surgery. Future studies need to focus on the ability of tests to predict outcome from steroid intervention.

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