Relative adrenal insufficiency and hemodynamic status in cardiopulmonary bypass surgery patients. A prospective cohort study.
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.
Iribarren
José L
JL
Critical Care Department, Hospital Universitario de Canarias, Ofra s/n, La Cuesta, 38320 La Laguna, Tenerife, España. joseluis.iribarren@gmail.com
Jiménez
Juan J
JJ
Hernández
Domingo
D
Lorenzo
Lisset
L
Brouard
Maitane
M
Milena
Antonio
A
Mora
María L
ML
Martínez
Rafael
R
D000309:Adrenal Insufficiency / Q000139:chemically induced* / Q000175:diagnosis / Q000209:etiology; D018686:Anesthetics, Intravenous / Q000009:adverse effects*; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D003366:Cosyntropin; D005045:Etomidate / Q000009:adverse effects*; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D011182:Postoperative Care; D011183:Postoperative Complications; D012307:Risk Factors; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D018686:Anesthetics, Intravenous; D014662:Vasoconstrictor Agents; D003366:Cosyntropin; D006854:Hydrocortisone; D005045:Etomidate
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