Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

Crawford, Jack H.; Hull, Matthew S.; Borasino, Santiago; Steenwyk, Brad L.; Wall, Kevin; Alten, Jeffrey A.

doi:10.1111/pan.13013

Cited by 17 publications

(13 citation statements)

References 18 publications

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“…We did not specifically identify patients that had received cardiopulmonary bypass therapy. As for postoperative RAI, a recent study found that using a low-dose CSS (1 µg cosyntropin), investigators noted that 1/3 of neonates undergoing cardiac surgery developed RAI after surgery (based on a cutoff of +9 µg/dL change) [22]; however, these patients had received methylprednisolone prior to the CSS in preparation for the cardiopulmonary bypass. Thus, these patients may have had their hypothalamic-pituitary-adrenal axis iatrogenically suppressed.…”

Section: Discussionmentioning

confidence: 99%

Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit

et al. 2017

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Background: The cosyntropin stimulation study (CSS) measures the patient’s ability to adequately mount a cortisol response. Clinically, CSS results may not be used to guide hydrocortisone use. The objective of this study was to examine how the CSS results are associated with clinical parameters, mortality/disease severity, and use of glucocorticoids in pediatric patients with catecholamine- and fluid-resistant shock. Methods: This was a retrospective cohort study of patients who had a CSS during 2009–2014 in the intensive care unit at a children’s hospital. Data collected included clinical variables, mortality, biochemical studies, and glucocorticoid use. PRISM III scores were used to determine the association between CSS results and disease severity. Adequate response to cosyntropin was defined as peak cortisol of 18 µg/dL or higher. Results: Of the 76 patients that underwent CSS, 68 (89%) had an adequate response to cosyntropin. There was a positive correlation between peak cortisol and PRISM III score (r = 0.45, r² = 0.2). Glucocorticoid was administered in 52/76 (68%) despite several patients with normal CSS results. Conclusions: Sicker patients were more likely to have an adequate response to CSS. Clinically, glucocorticoid supplementation was not based on CSS results. Further prospective studies are needed to elucidate if CSS is a valuable clinical tool.

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Section: Discussionmentioning

confidence: 99%

Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit

et al. 2017

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“…Only the patients diagnosed with adrenal insufficiency exhibited a significant increase in mean blood pressure and urine output in response to hydrocortisone administration [ 59 ]. A recent study by Crawford et al [ 57 ] aimed to correlate relative adrenal insufficiency to clinical outcomes in 40 neonates undergoing complex heart surgery. Like the studies discussed above, all patients received preoperative methylprednisolone.…”

Section: Resultsmentioning

confidence: 99%

Corticosteroids in Pediatric Heart Surgery: Myth or Reality

et al. 2018

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Background: Corticosteroids have been administered prophylactically for more than 60 years in pediatric heart surgery, however, their use remains a matter of debate. There are three main indications for corticosteroid use in pediatric heart surgery with the use of cardiopulmonary bypass (CPB): (1) to blunt the systemic inflammatory response (SIRS) induced by the extracorporeal circuit; (2) to provide perioperative supplementation for presumed relative adrenal insufficiency; (3) for the presumed neuroprotective effect during deep hypothermic circulatory arrest operations. This review discusses the current evidence behind the use of corticosteroids in these three overlapping areas.Materials and Methods: We conducted a structured research of the literature using PubMed and MEDLINE databases to November 2017 and additional articles were identified by cross-referencing.Results: The evidence suggests that there is no correlation between the effect of corticosteroids on inflammation and their effect on clinical outcome. Due to the limitations of the available evidence, it remains unclear if corticosteroids have an impact on early post-operative outcomes or if there are any long-term effects. There is a limited understanding of the hypothalamic-pituitary-adrenal axis function during cardiac surgery in children. The neuroprotective effect of corticosteroids during deep hypothermic circulatory arrest surgery is controversial.Conclusions: The utility of steroid administration for pediatric heart surgery with the use of CPB remains a matter of debate. The effect on early and late outcomes requires clarification with a large multicenter randomized trial. More research into the understanding of the adrenal response to surgery in children and the effect of corticosteroids on brain injury is warranted.

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“…Due to the complexity of open-heart surgery, the processes of CPB and circulatory arrest require relatively long time periods, during which the blood supply may become blocked, leading to myocardial ischemia and hypoxia ( 31 ). After the aorta is opened, the heart is re-perfused with systemic blood flow and a large number of white blood cells accumulate in the myocardial microvascular bed and interact with inflammatory mediators, resulting in the release of oxygen free radicals and other toxic substances, which ultimately leads to ischemic injury and an enhanced systemic inflammatory response ( 8 , 32 ). Accordingly, these events increase the incidence of postoperative malignant arrhythmia and low cardiac output syndrome.…”

Section: Discussionmentioning

confidence: 99%

Hydrogen‑rich solution attenuates myocardial injury caused by cardiopulmonary bypass in rats via the Janus‑activated kinase 2/signal transducer and activator of transcription 3 signaling pathway

et al. 2018

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The incidence of complications and mortality following open-heart surgery with cardiopulmonary bypass (CPB) is associated with the severity of the myocardial injury that occurs during surgery. Hydrogen-rich solution (HRS) may prevent antioxidant stress and inhibit apoptosis and inflammation. The present study was designed to investigate the effects of HRS on CPB-induced myocardial injury, and to investigate its potential regulation of the Janus-activated kinase 2/signal transducer and activator of transcription 3 (JAK2/STAT3) pathway. The HRS treatment resulted in the significant upregulation of malonyl dialdehyde (MDA) and myeloperoxidase (MPO), whilesuperoxide dismutase (SOD) levels were significantly downregulated, compared with the Sham group (P<0.05). Additionally, HRS treatment improved myocardial injury, and decreased the expression levels of cardiac troponins, heart-type fatty acid binding protein, interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, MDA and MPO, and increased SOD release in CPB rats (P<0.05). Additionally, in the CPB group without the HRS treatment, the expression levels of B-cell lymphoma (Bcl)-2, JAK2, phospho-JAK2 (p-JAK2), STAT3 and phospho-STAT3 (p-STAT3) were significantly decreased, and Bax was significantly increased, compared with the Sham group (P<0.05). By contrast, compared with the CPB group, the expression levels of B-cell lymphoma 2 (Bcl-2), JAK2, phosphorylated (p)-JAK2, STAT3 and p-STAT3 in the HRS group were significantly increased, and Bcl-2-associated X protein expression was significantly decreased (P<0.05). In JAK2 knockdown experiments using siRNA, HRS treatment following hypoxia/reoxygenation also significantly increased the viability of myocardial cells, decreased the rate of myocardial cell apoptosis, elevated the levels of SOD and suppressed the release of MDA and lactate dehydrogenase in the control siRNA and CPB groups (P<0.05). Furthermore, JAK2 siRNA attenuated these protective effects of HRS (P<0.05 vs. control siRNA, HRS and CPB groups). Additionally, the results demonstrated that the HRS treatment significantly increased the expression levels of p-JAK2, p-STAT3 and Bcl-2 in myocardial cells following hypoxia and decreased Bax expression in the control siRNA and CPB groups (P<0.05). In addition, JAK2 siRNA was determined to attenuate these effects of HRS (P<0.05 vs. control siRNA, HRS and CPB groups). Taken together, these results indicated that HRS may alleviate CPB-induced myocardial injury, inhibit myocardial cell apoptosis and protect myocardial cells through regulation of the JAK2/STAT3 signaling pathway.

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Adrenal insufficiency in neonates after cardiac surgery with cardiopulmonary bypass

Cited by 17 publications

References 18 publications

Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit

Correlation between Cosyntropin Stimulation Study and Disease Severity in Children with Fluid- and Catecholamine-Refractory Shock in the Pediatric and Cardiovascular Intensive Care Unit

Corticosteroids in Pediatric Heart Surgery: Myth or Reality

Hydrogen‑rich solution attenuates myocardial injury caused by cardiopulmonary bypass in rats via the Janus‑activated kinase 2/signal transducer and activator of transcription 3 signaling pathway

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