Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients. A prospective cohort study

José L Iribarren, Juan J Jiménez, Domingo Hernández, Lisset Lorenzo, Maitane Brouard, Antonio Milena, María L Mora, Rafael Martínez, José L Iribarren, Juan J Jiménez, Domingo Hernández, Lisset Lorenzo, Maitane Brouard, Antonio Milena, María L Mora, Rafael Martínez

Abstract

Background: The objectives of this study were to determine the risk factors for relative adrenal insufficiency in cardiopulmonary bypass patients and the impact on postoperative vasopressor requirements.

Methods: Prospective cohort study on cardiopulmonary bypass patients who received etomidate or not during anesthetic induction. Relative adrenal insufficiency was defined as a rise in serum cortisol <or= 9 microg/dl after the administration of 250 microg of consyntropin. Plasma cortisol levels were measured preoperatively, immediately before, 30, 60, and 90 minutes after the administration of cosyntropin, and at 24 hours after surgery.

Results: 120 elective cardiopulmonary bypass patients were included. Relative adrenal insufficiency (Deltacortisol <or=9 microg/dl) incidence was 77.5%. 78 patients received etomidate and 69 (88%) of them developed relative adrenal insufficiency, (P < 0.001). Controlling for clinical characteristics with a propensity analysis, etomidate was the only independent risk factor associated with relative adrenal insufficiency (OR 6.55, CI 95%: 2.47-17.4; P < 0.001). Relative adrenal insufficiency patients showed more vasopressor requirements just after surgery (P = 0.04), and at 4 hours after surgery (P = 0.01). Pre and post-test plasma cortisol levels were inversely associated with maximum norepinephrine dose (rho = -0.22, P = 0.02; rho = -0.18, P = 0.05; rho = -0.21, P = 0.02; and rho = -0.22, P = 0.02, respectively).

Conclusions: Relative adrenal insufficiency in elective cardiopulmonary bypass patients may induce postoperative vasopressor dependency. Use of etomidate in these patients is a modifiable risk factor for the development of relative adrenal insufficiency that should be avoided.

Figures

Figure 1
Figure 1
Population study flow chart.
Figure 2
Figure 2
Cortisol levels in etomidate and non-etomidate patients. Baseline and stimulated plasma cortisol levels regarding the use of etomidate. Black arrow shows cardiac surgery. 250 μg corticotropin test was carried out at 4 hours after surgery. Values are means and 95% confidence intervals. * = P < 0.001 between groups.
Figure 3
Figure 3
Norepinephrine requirements. Postoperative norepinephrine dose per group with or without relative renal insufficiency. Values are means and standard deviations.

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