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Mpody C, Patel AB, Smoyer WE, Tobias JD, Nafiu OO. Metabolomic profiling of pediatric post-tonsillectomy pain: A proof-of-concept study. Paediatr Anaesth 2024; 34:610-618. [PMID: 38466029 DOI: 10.1111/pan.14876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/13/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Tonsillectomies are among the most common surgical procedures in children, with over 500 000 cases annually in the United States. Despite universal administration of intraoperative opioid analgesia, three out of five children undergoing tonsillectomy report moderate-to-severe pain upon recovering from anesthesia. The underlying molecular mechanisms of post-tonsillectomy pain are not well understood, limiting the development of targeted treatment strategies. Our study aimed to identify candidate serum metabolites associated with varying severity of post-tonsillectomy pain. METHODS Venous blood samples and pain scores were obtained from 34 children undergoing tonsillectomy ± adenoidectomy, and metabolomic analysis was performed. Supervised orthogonal projections to latent structures discriminant analysis were employed to identify differentially expressed metabolites between children with severe and mild pain, as well as between moderate and mild pain. RESULTS Pain scores differentiated children as mild (n = 6), moderate (n = 14), or severe (n = 14). Four metabolites (fatty acid 18:0(OH), thyroxine, phosphatidylcholine 38:5, and branched fatty acids C27H54O3) were identified as candidate biomarkers that differentiated severe vs. mild post-tonsillectomy pain, the combination of which yielded an AUC of 0.91. Similarly, four metabolites (sebacic acid, dicarboxylic acids C18H34O4, hydroxy fatty acids C18H34O3, and myristoleic acid) were identified as candidate biomarkers that differentiated moderate vs. mild post-tonsillectomy pain, with AUC values ranging from 0.85 to 0.95. CONCLUSION This study identified novel candidate biomarker panels that effectively differentiated varying severity of post-tonsillectomy pain. Further research is needed to validate these data and to explore their clinical implications for personalized pain management in children undergoing painful surgeries.
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Affiliation(s)
- Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Ambrish B Patel
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA
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Küçük Alemdar D, Bulut A, Yilmaz G. Impact of music therapy and hand massage in the pediatric intensive care unit on pain, fear and stress: Randomized controlled trial. J Pediatr Nurs 2023; 71:95-103. [PMID: 37230011 DOI: 10.1016/j.pedn.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE This study was performed with the aim of assessing the effect of music therapy and hand massage on pain, fear and stress among 12-18 year-old adolescents treated in the pediatric intensive care unit (PICU). DESIGN This study was a randomized controlled trial, with single-blind design. METHODS The adolescents were divided into groups with 33 receiving hand massage, 33 receiving music therapy and 33 in the control group. Collection of data used the Wong-Baker FACES (WB-FACES) Pain Rating Scale, Children's Fear Scale (CFS) and blood cortisol levels. FINDINGS In the study, adolescents in the music therapy group had lower mean points for WB-FACES before, during and after the procedure by a significant level compared to the control group (p < 0.05). Additionally, the CFS mean points before and during the procedure were lowest in the music therapy group, while the music therapy and massage groups were determined to have lower points by a significant level after the procedure compared to the control group (p < 0.05). However, when the mean cortisol levels of adolescents before the procedure and on the 1st and 2nd day after the procedure were compared, there was no significant difference between the groups (p > 0.05). CONCLUSIONS It was determined that hand massage and music therapy were more effective than standard care at reducing pain and fear levels during blood drawing among 12-18-year-old adolescents in the PICU. PRACTICE IMPLICATIONS Nurses may use music therapy and hand massage to manage fear and pain related to blood drawing in the PICU.
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Affiliation(s)
- Dilek Küçük Alemdar
- Ordu University, Faculty of Health Sciences, Department of Pediatrics Nursing Ordu,Turkey.
| | - Azime Bulut
- Giresun University, Faculty of Medicine, Department of Anesthesia and Reanimation, Giresun/Turkey
| | - Gamze Yilmaz
- Ağrı İbrahim Çeçek University, Faculty of Health Sciences, Department of Pediatrics Nursing Ağrı, Turkey
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3
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Gomes HDS, Anabuki AA, Viana KA, Abreu LG, Batista AC, Hosey MT, Costa LR. Assessment of child's dental anxiety/fear and stress during dental treatment: a systematic review by CEDACORE. Braz Oral Res 2022; 36:e067. [PMID: 36507754 DOI: 10.1590/1807-3107bor-2022.vol36.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 02/18/2022] [Indexed: 12/15/2022] Open
Abstract
There is a lack of evidence on the correlation between salivary biomarkers and subjective measures of dental fear and anxiety in children. This systematic review aimed to retrieve the scientific evidence comparing the results of dental anxiety measured by salivary biomarkers with patient-reported outcomes in pediatric dental setting. The PECOS was as follows: population: pediatric patients aged ≤ 18 years; exposure: patient-reported outcome measures, such as scales and/or questionnaires; comparator: salivary biomarkers; outcome: anxiety, fear, phobia or stress during dental treatment; study design: observational studies or controlled trials. Electronic searches were conducted in PubMed, Scopus, Web of Science, and Ovid databases. Studies that compared scales/questionnaires and salivary biomarkers for the evaluation of dental anxiety, fear, and stress in children/adolescents during dental treatment were included. Certainty of evidence was assessed with GRADE. Risk of bias of the included studies was assessed with the Cochrane tool or the University of Adelaide tool. From the 314 studies identified, eight were included. Participants' age ranged from three to 13 years. The most used salivary biomarkers and instruments were cortisol and the Dental Subscale of the Children's Fear Survey Schedule, respectively. Most studies showed a weak correlation between objective and subjective measures. The main issues regarding bias were on allocation concealment, blinding of assessors, follow up, and exposure assessment. Certainty of evidence was low/very low. Evidence of salivary biomarkers and patient-reported outcome measures to investigate anxiety, fear and stress in children during in the dental environment is limited. There was no correlation between subjective and objective measures in almost all included studies.
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Affiliation(s)
- Heloisa de Sousa Gomes
- Universidade Federal de Goiás - UFG, School of Dentistry, Postgraduate Program in Dentistry, Goiânia, GO, Brasil
| | - Anna Alice Anabuki
- Universidade Federal de Goiás - UFG, School of Dentistry, Postgraduate Program in Dentistry, Goiânia, GO, Brasil
| | - Karoline Alves Viana
- Universidade Federal de Goiás - UFG, School of Dentistry, Postgraduate Program in Dentistry, Goiânia, GO, Brasil
| | - Lucas Guimarães Abreu
- Universidade Federal de Minas Gerais - UFMG, School of Dentistry, Department of Child and Adolescent Oral Health, Belo Horizonte, MG, Brasil
| | - Aline Carvalho Batista
- Universidade Federal de Goiás - UFG, School of Dentistry, Postgraduate Program in Dentistry, Goiânia, GO, Brasil
| | - Marie Therese Hosey
- King's College London, Centre for Oral Clinical and Translational Sciences, Faculty of Dentistry, Oral and Craniofacial, London, United Kingdom
| | - Luciane Rezende Costa
- Universidade Federal de Goiás - UFG, School of Dentistry, Postgraduate Program in Dentistry, Goiânia, GO, Brasil
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 157] [Impact Index Per Article: 78.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Kim MH, Kim NY, Yoo YC, Kong HJ, Lee HS, Jo A, Bai SJ. Influence of Deep Neuromuscular Blockade on Perioperative Stress Response in Patients Undergoing Robot-Assisted Gastrectomy: A Prospective Double-Blinded Randomized-Controlled Trial. J Pers Med 2021; 11:jpm11121308. [PMID: 34945780 PMCID: PMC8703636 DOI: 10.3390/jpm11121308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022] Open
Abstract
Attenuating the intraoperative stress response is crucial; however, the effect of neuromuscular blockade (NMB) on surgical stress is not completely understood. We aimed to investigate the effects of NMB on the perioperative stress response during robot-assisted gastrectomy. Patients were assigned to the deep or moderate NMB group. Serum cortisol, prolactin, and interleukin-6 (IL-6) levels and natural killer (NK) cell percentage were measured before anesthesia induction, 90 min after pneumoperitoneum, operation end (OPEnd), and postoperative day 1. Additionally, C-reactive protein (CRP) and albumin levels were estimated. Additionally, intraoperative heart rate variability was evaluated. The deep NMB group showed significantly lower levels of low-frequency/high-frequency (HF) ratio at OPEnd compared to the moderate NMB group (1.4 ± 0.2 vs. 2.2 ± 0.3, respectively; Bonferroni corrected p = 0.039). Furthermore, HF power in the deep NMB group was significantly higher at OPEnd than that in the moderate NMB group (45.2 ± 3.6 vs. 33.8 ± 4.0, respectively; Bonferroni corrected p = 0.044). However, no significant differences in cortisol, prolactin, IL-6, CRP, and albumin levels and NK cell percentage were found between the two groups. The degree of NMB may have similar effects on stress-related biological markers in patients undergoing robot-assisted gastrectomy.
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Affiliation(s)
- Myoung Hwa Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea; (M.H.K.); (A.J.)
| | - Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
| | - Young Chul Yoo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
| | - Hee Jung Kong
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea;
| | - Arim Jo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea; (M.H.K.); (A.J.)
| | - Sun Joon Bai
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea; (N.Y.K.); (Y.C.Y.); (H.J.K.)
- Correspondence: ; Tel.: +82-2-2228-4435
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Heath C, Siafarikas A, Sommerfield A, Ungern‐Sternberg BS. Peri-operative steroid management in the paediatric population. Acta Anaesthesiol Scand 2021; 65:1187-1194. [PMID: 34263943 DOI: 10.1111/aas.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/14/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with adrenal insufficiency are at risk of adrenal crisis, a potentially life-threatening emergency in the peri-operative period due to their attenuated ability to mount a cortisol response. There is a lack of standardization regarding peri-operative stress-dose glucocorticoids in paediatric clinical practice with the absence of agreed protocols. For the individual patient, the risk of adrenal crisis must be weighed against the potential adverse clinical outcomes associated with unnecessary or supra-physiologic glucocorticoid dosing in susceptible patients. Specific clinical concerns in the paediatric population include osteopenia, growth restriction and increased risk of cardiovascular disease in adulthood. This review aimed to identify and evaluate available literature in the field of peri-operative stress-dose glucocorticoids. METHODS A comprehensive literature search was conducted to construct a narrative review. RESULTS The outcome of this review identified that paediatric patients, unlike adults, do not show a graded response to surgical stress with implications for glucocorticoid stress dose regimens for general anaesthesia and less invasive surgical procedures. The studies highlight a lack of information on physiological steroid responses to stress situations and differences in the approach to glucocorticoid replacement strategies in the paediatric population. CONCLUSION The review identified there is a lack of high-quality paediatric-specific studies evaluating appropriate stress-dose glucocorticoid regimens in paediatric patients with or at risk of adrenal insufficiency. Further research is needed to establish clear evidence-based clinical guidelines for paediatric peri-operative practice regarding steroid stress dosing in adrenal insufficiency. Current knowledge would suggest that a balanced view of risks and benefits should be taken appropriate to the clinical context, to dictate peri-operative stress-dose glucocorticoids use that permits safe perioperative management.
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Affiliation(s)
- Chloe Heath
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
| | - Aris Siafarikas
- Department of Paediatric Endocrinology Perth Children’s Hospital Perth Western Australia Australia
- Faculty of Medicine, Paediatrics The University of Western Australia Nedlands Western Australia Australia
- Institute for Health ResearchUniversity of Notre Dame Fremantle Western Australia Australia
- Telethon Kids Institute Perth Western Australia Australia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
- Perioperative Medicine Team Telethon Kids Institute Perth Western Australia Australia
| | - Britta S. Ungern‐Sternberg
- Department of Anaesthesia and Pain Management Perth Children’s Hospital Perth Western Australia Australia
- Perioperative Medicine Team Telethon Kids Institute Perth Western Australia Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine Medical School The University of Western Australia Perth Western Australia Australia
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Yau M, Jacob M, Orton S, Howell JD, Lekarev O, Vogiatzi MG, Poppas D, Nimkarn S, Lin-Su K. Perioperative stress dose steroid management of children with classical congenital adrenal hyperplasia: Too much or too little? J Pediatr Urol 2021; 17:654.e1-654.e6. [PMID: 34266748 DOI: 10.1016/j.jpurol.2021.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/21/2021] [Accepted: 06/24/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with congenital adrenal hyperplasia (CAH) are at risk for adrenal crises in the perioperative period and require higher doses of glucocorticoids. However, there are no specific protocols detailing the appropriate stress dosing required for children with CAH undergoing surgery with anesthesia. OBJECTIVE To evaluate CAH patients using our current hydrocortisone stress dose surgical protocol. We hypothesized that current clinical protocols may overestimate the endogenous response to perioperative stress. STUDY DESIGN 14 children with CAH scheduled to have genital surgery and a control group of 10 unaffected children scheduled to have cardiac or urologic surgery (of a similar duration) were evaluated in a prospective observational study. Urinary free cortisol (UFC) and urinary 17-hydroxycorticosteroids (17-OHCS) per body surface area were measured in the postoperative period. RESULTS UFC levels were significantly higher in CAH patients (115.8 ± 24.6 nmol/m2) than in controls (26.5 ± 12.2 nmol/m2), P < 0.05.17-OHCS levels were also higher in CAH patients than in controls (6.5 ± 0.5 nmol/m2 vs. 3.4 ± 0.5 nmol/m2), P < 0.05). CONCLUSION In the immediate postoperative period, urinary cortisol and its metabolites are significantly higher in pediatric CAH patients receiving stress dose corticosteroids compared to controls. Results suggest that the amount of hydrocortisone given during our stress dose protocol may be higher than physiologic needs. Future dynamic studies are needed to determine appropriate perioperative and postoperative cortisol requirements in pediatric CAH patients in order to develop optimal stress dose regimens.
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Affiliation(s)
- Mabel Yau
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Pediatric Endocrinology, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY, 10028, USA.
| | - Marianne Jacob
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Sarah Orton
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Pediatric Endocrinology, Morris Heights Health Center, 85 W. Burnside Ave, Bronx, NY, 10453, USA.
| | - Joy D Howell
- Pediatric Critical Care Medicine, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Oksana Lekarev
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Maria G Vogiatzi
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Pediatric Endocrinology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Dix Poppas
- Pediatric Urology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
| | - Saroj Nimkarn
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA; Children's Center, Bumrungrad International Hospital, 33 Soi Sukhumvit 3, Khlong Toei Nuea, Watthana, Bangkok, 110110, Thailand.
| | - Karen Lin-Su
- Pediatric Endocrinology, Weill Cornell Medicine/Komansky Children's Hospital/New York Presbyterian Hospital, 525 E. 68th Street, New York, NY, 10021, USA.
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Vercueil A. Guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency: a reply. Anaesthesia 2020; 75:1398-1399. [PMID: 32621301 DOI: 10.1111/anae.15191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 12/19/2022]
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9
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Morgan KJ, Rossi M, Chemaitilly W. The role of glucocorticoid supplementation in children with secondary adrenal insufficiency undergoing anaesthesia for imaging examinations. Anaesthesia 2020; 75:1395-1396. [DOI: 10.1111/anae.15031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- K. J. Morgan
- St. Jude Children's Research Hospital Memphis TN USA
| | - M. Rossi
- St. Jude Children's Research Hospital Memphis TN USA
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10
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Urmson K. Stress dose steroids: the dogma persists. Can J Anaesth 2020; 67:276-277. [PMID: 31549340 DOI: 10.1007/s12630-019-01487-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kristine Urmson
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, SK, Canada.
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Sazhin AV, Nechay TV, Titkova SM, Tyagunov AE, Anurov MV, Melnikov-Makarchuk KY, Tyagunov AA, Ermakov IV, Glagolev NS, Kurashinova LS, Ivanova EA, Nechay VS, Karpov AV, Mirzoyan AT, Ivakhov GB, Balakirev YS. [Comparison of standard and fast track rehabilitation in patients with acute appendicitis. Intermediate results of multicenter prospective randomized trial]. Khirurgiia (Mosk) 2019:15-23. [PMID: 30307416 DOI: 10.17116/hirurgia2018090115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To analyze outcomes of fast track rehabilitation in patients with acute appendicitis. MATERIAL AND METHODS Prospective, randomized multi-center trial including 86 patients was conducted. There were 38 patients in the main group and 48 in the control group. All patients underwent laparoscopic appendectomy under endotracheal anesthesia. Protocol included informing, no premedication, glucose infusion prior to surgery, antibiotics administration, mesoappendix excision, limited deployment of drainage tubes, intraabdominal prolonged anesthesia, minimal pneumoperitoneum, limited irrigation, minimum power monopolar electrocautery, antiemetics, early activation and eating (2 and 6 hours after surgery). Pain was evaluated by visual-analogue scale. Auscultative peristalsis was considered every 2 hours after surgery. Cortisol level was assessed preoperatively, in 6 and 12-24 hours after surgery in 11 (29%) and 15 (31%) patients of the main and control groups respectively. Discharge criteria: no leukocytosis, fever and pain syndrome requiring anesthesia, no signs of complications and patient's consent. RESULTS Terms of disease, gender, age and comorbidities were similar in all patients. Duration of surgery under minimal pneumoperitoneum and standard pressure was also similar: 69.2±3.98 and 70.9±3.89 min (p=0.762). Pain syndrome grade and need for analgesics were significantly lower in the main group within entire follow-up. Pain syndrome was absent at the 1st postoperative day in 16 (42%) and 2 (4.1%) patients of both groups, respectively (score 0-1). Phrenic nerve syndrome was observed in 36.8% of the main group and 60.4% of the control group (p=0.05). Incidence of dyspepsia and terms of peristalsis onset were similar. Length of hospital-stay was 1.45 days in the main group and 3.15 days in the control group (p=0.002). In the main group 18 (47%) patients were discharged on the first day after surgery. There were only 4 (8.3%) patients with similar hospital-stay in the control group (p<0.001). There were no repeated hospitalizations. Postoperative cortisol concentration was similar in both groups as well as in complicated and uneventful postoperative period. In the main group postoperative intestinal paresis (Clavien-Dindo grade 2) occurred in 1 patient. In the control group 7 patients had postoperative infiltrate and 1 patient - intestinal paresis (Clavien-Dindo grade 2). Postoperative drainage tube was deployed in 3 out of 7 patients with postoperative infiltrates and 6 of them received antibiotic therapy. Medication was successfully applied in all patients with complications. CONCLUSION There are some advantages of FTR for AA including reduced pain syndrome, morbidity and less length of hospital-stay. Issue of cortisol concentration requires further trials.
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Affiliation(s)
- A V Sazhin
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - T V Nechay
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - S M Titkova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A E Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - M V Anurov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - K Yu Melnikov-Makarchuk
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - A A Tyagunov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - I V Ermakov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - N S Glagolev
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - L S Kurashinova
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - E A Ivanova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V S Nechay
- Medical Institute of Tula State University
| | - A V Karpov
- Moscow Clinical Hospital #4, Moscow, Russia
| | - A T Mirzoyan
- City Clinical Hospital #29 of Moscow Healthcare Department, Moscow, Russia
| | - G B Ivakhov
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
| | - Yu S Balakirev
- Pirogov Russian National Research Medical University, Moscow, Russia; City Clinical Hospital #1 of Moscow Healthcare Department, Moscow, Russia
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Morgan KJ, Chemaitilly W, Rossi M, Li Y, Han Y, Merchant TE. Supplemental glucocorticoids and anesthesia for noninvasive indications in children with central adrenal insufficiency: A retrospective study. Paediatr Anaesth 2019; 29:292-294. [PMID: 30632232 DOI: 10.1111/pan.13586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kyle J Morgan
- Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wassim Chemaitilly
- Division of Endocrinology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Michael Rossi
- Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yimei Li
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yuanyuan Han
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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13
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 538] [Impact Index Per Article: 89.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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14
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Nour MA, Gill H, Mondal P, Inman M, Urmson K. Perioperative care of congenital adrenal hyperplasia - a disparity of physician practices in Canada. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2018; 2018:8. [PMID: 30214458 PMCID: PMC6131860 DOI: 10.1186/s13633-018-0063-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 08/26/2018] [Indexed: 11/29/2022]
Abstract
Background Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most common cause of primary adrenal insufficiency in children. Current guidelines recommend the use of perioperative stress dose (supraphysiologic) glucocorticoids for children with CAH undergoing anesthesia, although a perceived difference in practice patterns among Canadian pediatric subspecialists prompted an assessment of perioperative glucocorticoid administration. Methods We performed a cross-sectional survey of Canadian Pediatric Anesthesia Society (CPAS) and Canadian Pediatric Endocrine Group (CPEG) members via membership email lists to assess reported practice patterns to select clinical scenarios. Results Responses were collected from 49 anesthesiologists and 37 pediatric endocrinologists. Less than half of anesthesiologists reported they would provide stress dose corticosteroids for patients undergoing cystoscopy while a significant majority of pediatric endocrinologists reported they would recommend stress dose corticosteroid administration (45% vs 92% respectively, p < 0.0001). Twenty-one percent of anesthesiologists reported they would not provide stress dose corticosteroids for patients undergoing laparotomy. Pediatric endocrinologists reported they were more likely to refer to guidelines for management of stress dose steroids (84% vs 51%, p < 0.001), with many Canadian pediatric endocrinologists reporting to use institution specific guidelines. Conclusions Our results demonstrate a clear difference in the reported approach to perioperative stress dose steroids between pediatric anesthesiologists and pediatric endocrinologists which may impact patient care. Further dialogue is required to address this apparent discrepancy in practice patterns and future research is needed to provide evidence-based practice recommendations. Electronic supplementary material The online version of this article (10.1186/s13633-018-0063-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Munier A Nour
- 1Division of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, University of Saskatchewan, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Hardave Gill
- 2Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Canada
| | - Prosanta Mondal
- 3Clinical Research Support Unit, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Mark Inman
- 1Division of Pediatric Endocrinology, Department of Pediatrics, College of Medicine, University of Saskatchewan, Royal University Hospital, 103 Hospital Drive, Saskatoon, SK S7N 0W8 Canada
| | - Kristine Urmson
- 2Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Saskatchewan, Saskatoon, Canada
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15
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El-Maouche D, Hargreaves CJ, Sinaii N, Mallappa A, Veeraraghavan P, Merke DP. Longitudinal Assessment of Illnesses, Stress Dosing, and Illness Sequelae in Patients With Congenital Adrenal Hyperplasia. J Clin Endocrinol Metab 2018; 103:2336-2345. [PMID: 29584889 PMCID: PMC6276663 DOI: 10.1210/jc.2018-00208] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/19/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with congenital adrenal hyperplasia (CAH) are at risk for life-threatening adrenal crises. Management of illness episodes aims to prevent adrenal crises. OBJECTIVE We evaluated rates of illnesses and associated factors in patients with CAH followed prospectively and receiving repeated glucocorticoid stress dosing education. METHODS Longitudinal analysis of 156 patients with CAH followed at the National Institutes of Health Clinical Center over 23 years was performed. The rates of illnesses and stress-dose days, emergency room (ER) visits, hospitalizations, and adrenal crises were analyzed in relation to phenotype, age, sex, treatment, and hormonal evaluations. RESULTS A total of 2298 visits were evaluated. Patients were followed for 9.3 ± 6.0 years. During childhood, there were more illness episodes and stress dosing than adulthood (P < 0.001); however, more ER visits and hospitalizations occurred during adulthood (P ≤ 0.03). The most robust predictors of stress dosing were young age, low hydrocortisone and high fludrocortisone dose during childhood, and female sex during adulthood. Gastrointestinal and upper respiratory tract infections (URIs) were the two most common precipitating events for adrenal crises and hospitalizations across all ages. Adrenal crisis with probable hypoglycemia occurred in 11 pediatric patients (ages 1.1 to 11.3 years). Undetectable epinephrine was associated with ER visits during childhood (P = 0.03) and illness episodes during adulthood (P = 0.03). CONCLUSIONS Repeated stress-related glucocorticoid dosing teaching is essential, but revised age-appropriate guidelines for the management of infectious illnesses are needed for patients with adrenal insufficiency that aim to reduce adrenal crises and prevent hypoglycemia, particularly in children.
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Affiliation(s)
- Diala El-Maouche
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Ninet Sinaii
- Biostatistics and Clinical Epidemiology Service, National Institutes of Health,
Bethesda, Maryland
| | - Ashwini Mallappa
- National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human
Development, National Institutes of Health, Bethesda, Maryland
- Correspondence and Reprint Requests: Deborah P. Merke, MD, National Institutes of Health Clinical Center, 10 Center
Drive, Room 1-2740, Bethesda, Maryland 20892. E-mail:
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Khoo B, Boshier PR, Freethy A, Tharakan G, Saeed S, Hill N, Williams EL, Moorthy K, Tolley N, Jiao LR, Spalding D, Palazzo F, Meeran K, Tan T. Redefining the stress cortisol response to surgery. Clin Endocrinol (Oxf) 2017; 87:451-458. [PMID: 28758231 DOI: 10.1111/cen.13439] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 11/30/2022]
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.
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Affiliation(s)
- Bernard Khoo
- Endocrinology, Division of Medicine, University College London, Royal Free Hospital, London, UK
| | - Piers R Boshier
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Alexander Freethy
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - George Tharakan
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Samerah Saeed
- Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Neil Hill
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Emma L Williams
- Department of Clinical Biochemistry, North West London Pathology, Charing Cross Hospital, London, UK
| | - Krishna Moorthy
- Department of Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Neil Tolley
- Department of Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Long R Jiao
- Department of Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Duncan Spalding
- Department of Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Fausto Palazzo
- Department of Endocrine Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Karim Meeran
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
| | - Tricia Tan
- Section of Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Imperial College London, London, UK
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Besnier E, Clavier T, Compere V. The Hypothalamic–Pituitary–Adrenal Axis and Anesthetics. Anesth Analg 2017; 124:1181-1189. [DOI: 10.1213/ane.0000000000001580] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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18
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Du Y, Chen YJ, He B, Wang YW. The Effects of Single-Dose Etomidate Versus Propofol on Cortisol Levels in Pediatric Patients Undergoing Urologic Surgery: A Randomized Controlled Trial. Anesth Analg 2016; 121:1580-5. [PMID: 26496368 DOI: 10.1213/ane.0000000000000981] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The effects of general anesthetics on the hypothalamus-pituitary-adrenal axis and cortisol release in children are poorly characterized. Normal, daily fluctuation of cortisol levels complicates assessment of these effects. This study aimed to characterize the effects of etomidate compared with propofol on the normal cortisol secretory pattern in children undergoing urologic surgery by using a salivary cortisol assay. METHODS In this prospective, randomized, double-blind, controlled study, we recruited 80 children aged 3 to 12 years assigned ASA physical status I who were scheduled for urologic surgery and 11 healthy child volunteers. Before surgery, cortisol levels of the 11 volunteers and 15 study patients were tested from 7:00 AM to 9:00 PM every hour for 1 day. The study patients were then randomly allocated into an etomidate group and a propofol group, receiving etomidate 0.3 mg/kg (n = 38) or propofol 2 mg/kg (n = 39) and midazolam 0.1 mg/kg, fentanyl 2 μg/kg, and rocuronium 0.6 mg/kg for induction, respectively. The cortisol levels of the patients were assessed continuously for 2 days postoperatively. RESULTS The cortisol levels of the etomidate group were continuously and significantly lower than those of the propofol group from the time of discharge from the postanesthesia care unit (approximately 2:00 PM) until 8:00 AM the next morning (all P < 0.0001) and were significantly lower than before surgery at the same time points (all P < 0.0001). Except at 11:00 AM just before the operation, no significant differences in cortisol levels were detected before and after the operation in the propofol group (P max = 0.476, P min = 0.002). Also, no significant differences in clinical outcomes were detected between the 2 groups undergoing surgery (all P > 0.070). CONCLUSIONS Compared with propofol, a single induction dose of etomidate suppressed postoperative cortisol levels in healthy children undergoing urologic surgery. This suppression lasted approximately 24 hours and was not associated with any changes in clinical outcomes.
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Affiliation(s)
- Yi Du
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD, Husebye ES, Merke DP, Murad MH, Stratakis CA, Torpy DJ. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:364-89. [PMID: 26760044 PMCID: PMC4880116 DOI: 10.1210/jc.2015-1710] [Citation(s) in RCA: 904] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This clinical practice guideline addresses the diagnosis and treatment of primary adrenal insufficiency. PARTICIPANTS The Task Force included a chair, selected by The Clinical Guidelines Subcommittee of the Endocrine Society, eight additional clinicians experienced with the disease, a methodologist, and a medical writer. The co-sponsoring associations (European Society of Endocrinology and the American Association for Clinical Chemistry) had participating members. The Task Force received no corporate funding or remuneration in connection with this review. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to determine the strength of recommendations and the quality of evidence. CONSENSUS PROCESS The evidence used to formulate recommendations was derived from two commissioned systematic reviews as well as other published systematic reviews and studies identified by the Task Force. The guideline was reviewed and approved sequentially by the Endocrine Society's Clinical Guidelines Subcommittee and Clinical Affairs Core Committee, members responding to a web posting, and the Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. CONCLUSIONS We recommend diagnostic tests for the exclusion of primary adrenal insufficiency in all patients with indicative clinical symptoms or signs. In particular, we suggest a low diagnostic (and therapeutic) threshold in acutely ill patients, as well as in patients with predisposing factors. This is also recommended for pregnant women with unexplained persistent nausea, fatigue, and hypotension. We recommend a short corticotropin test (250 μg) as the "gold standard" diagnostic tool to establish the diagnosis. If a short corticotropin test is not possible in the first instance, we recommend an initial screening procedure comprising the measurement of morning plasma ACTH and cortisol levels. Diagnosis of the underlying cause should include a validated assay of autoantibodies against 21-hydroxylase. In autoantibody-negative individuals, other causes should be sought. We recommend once-daily fludrocortisone (median, 0.1 mg) and hydrocortisone (15-25 mg/d) or cortisone acetate replacement (20-35 mg/d) applied in two to three daily doses in adults. In children, hydrocortisone (∼8 mg/m(2)/d) is recommended. Patients should be educated about stress dosing and equipped with a steroid card and glucocorticoid preparation for parenteral emergency administration. Follow-up should aim at monitoring appropriate dosing of corticosteroids and associated autoimmune diseases, particularly autoimmune thyroid disease.
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Affiliation(s)
- Stefan R Bornstein
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Bruno Allolio
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Wiebke Arlt
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Andreas Barthel
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Andrew Don-Wauchope
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Gary D Hammer
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Eystein S Husebye
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Deborah P Merke
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - M Hassan Murad
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - Constantine A Stratakis
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
| | - David J Torpy
- Medizinische Klinik und Poliklinik III (S.R.B., A.B.), Universitätsklinikum Dresden, 01307 Dresden, Germany; Department of Endocrinology and Diabetes (S.R.B.), King's College London, London WC2R 2LS, United Kingdom; Department of Internal Medicine I (B.A.), Endocrine and Diabetes Unit, University Hospital Würzburg, 97080 Würzburg, Germany; Comprehensive Heart Failure Center (B.A.), University of Würzburg, 97080 Würzburg, Germany; Centre for Endocrinology, Diabetes, and Metabolism (W.A.), University of Birmingham, Birmingham B15 2TT, United Kingdom; Endokrinologikum Ruhr (A.B.), 44866 Bochum, Germany; Department of Pathology and Molecular Medicine (A.D.-W.), McMaster University, Hamilton, ON L8S 4L8, Canada; Hamilton Regional Laboratory Medicine Program (A.D.-W.), Hamilton, ON L8N 4A6, Canada; Department of Internal Medicine (G.D.H.), Division of Metabolism, Endocrinology, and Diabetes, and Cancer Center, University of Michigan, Ann Arbor, Michigan 48109; Department of Clinical Science, University of Bergen, and Department of Medicine, Haukeland University Hospital (E.S.H.), 5021 Bergen, Norway; National Institutes of Health Clinical Center (D.P.M.), Bethesda, Maryland 20814; Mayo Clinic, Division of Preventive Medicine (M.H.M.), Rochester, Minnesota 55905; Eunice Kennedy Shriver National Institute of Child Health and Human Development (C.A.S.), National Institutes of Health, Bethesda, Maryland 20892; and Endocrine and Metabolic Unit (D.J.T.), Royal Adelaide Hospital, University of Adelaide, Adelaide SA 5000, Australia
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Philla KQ, Min SB, Hefner JN, Howard RS, Reinhardt BJ, Nazareno LG, Vogt KS. Swallowed glucocorticoid therapy for eosinophilic esophagitis in children does not suppress adrenal function. J Pediatr Endocrinol Metab 2015; 28:1101-6. [PMID: 26024243 DOI: 10.1515/jpem-2014-0260] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 04/09/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effect of chronic swallowed glucocorticoids on adrenal function during the treatment of eosinophilic esophagitis (EoE) in children. METHODS Serum cortisol levels were obtained in children with EoE pre- and post-treatment with swallowed glucocorticoids. Exclusion criteria included those on any additional steroid therapy. Once diagnosed with EoE by esophageal biopsy, subjects were treated based on current standard of care with either swallowed fluticasone or budesonide. At the time of follow-up, esophagogastroduodenoscopy and blood sampling was repeated. Both pre- and post-treatment serum cortisol samples were collected fasting, between 07:00 and 10:00, and determined using a competitive binding method assay. The distribution of differences in cortisol levels between the pre- and post-treatment samples satisfied the assumption for normality and were subsequently analyzed using the paired t-test. RESULTS Pre- and post-treatment serum cortisol levels were examined in 14 children who met clinical and histological diagnostic criteria for EoE. Mean age was 10.1 years (range 2-17 years) with 71% male and 29% female subjects. Swallowed glucocorticoid treatment included fluticasone in 79% and budesonide in 21% of subjects. Mean dosage of fluticasone was 704 μg daily (range 220-880 μg daily) and budesonide 0.8 mg daily (range 0.5-1 mg daily), along with a mean treatment length of 17 weeks (range 8-43 weeks). No significant difference in serum cortisol was found following treatment with swallowed fluticasone or budesonide (mean change 1.9 μg/dL, p=0.75, SD of the change=21.2). CONCLUSIONS Swallowed glucocorticoid therapy does not appear to significantly affect the adrenal axis in children, and therefore, may represent a safe therapy for EoE.
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Webb EA, Krone N. Current and novel approaches to children and young people with congenital adrenal hyperplasia and adrenal insufficiency. Best Pract Res Clin Endocrinol Metab 2015; 29:449-68. [PMID: 26051302 DOI: 10.1016/j.beem.2015.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Congenital adrenal hyperplasia (CAH) represents a group of autosomal recessive conditions leading to glucocorticoid deficiency. CAH is the most common cause of adrenal insufficiency (AI) in the paediatric population. The majority of the other forms of primary and secondary adrenal insufficiency are rare conditions. It is critical to establish the underlying aetiology of each specific condition as a wide range of additional health problems specific to the underlying disorder can be found. Following the introduction of life-saving glucocorticoid replacement sixty years ago, steroid hormone replacement regimes have been refined leading to significant reductions in glucocorticoid doses over the last two decades. These adjustments are made with the aim both of improving the current management of children and young persons and of reducing future health problems in adult life. However despite optimisation of existing glucocorticoid replacement regimens fail to mimic the physiologic circadian rhythm of glucocorticoid secretion, current efforts therefore focus on optimising replacement strategies. In addition, in recent years novel experimental therapies have been developed which target adrenal sex steroid synthesis in patients with CAH aiming to reduce co-morbidities associated with sex steroid excess. These developments will hopefully improve the health status and long-term outcomes in patients with congenital adrenal hyperplasia and adrenal insufficiency.
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Affiliation(s)
- Emma A Webb
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
| | - Nils Krone
- School of Clinical & Experimental Medicine, University of Birmingham, Institute of Biomedical Research, Birmingham B15 2TT, UK.
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22
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Steroids: The Evidence. The Rationale for Perioperative Glucocorticoid Supplementation for Patients Under Chronic Steroid Treatment. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0093-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Adrenal insufficiency is a life-threatening condition that occurs secondary to impaired secretion of adrenal glucocorticoid and mineralocorticoid hormones. This condition can be caused by primary destruction or dysfunction of the adrenal glands or impairment of the hypothalamic-pituitary-adrenal axis. In children, the most common causes of primary adrenal insufficiency are impaired adrenal steroidogenesis (congenital adrenal hyperplasia) and adrenal destruction or dysfunction (autoimmune polyendocrine syndrome and adrenoleukodystrophy), whereas exogenous corticosteroid therapy withdrawal or poor adherence to scheduled corticosteroid dosing with long-standing treatment constitute the most common cause of acquired adrenal insufficiency. Although there are classic clinical signs (eg, fatigue, orthostatic hypotension, hyperpigmentation, hyponatremia, hyperkalemia, and hypoglycemia) of adrenal insufficiency, its early clinical presentation is most commonly vague and undefined, requiring a high index of suspicion. The relevance of early identification of adrenal insufficiency is to avoid the potential lethal outcome secondary to severe cardiovascular and hemodynamic insufficiency. The clinician must be aware of the need for increased corticosteroid dose supplementation during stress periods.
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Affiliation(s)
- Moises Auron
- Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, Cleveland, OH. Department of Pediatric Hospital Medicine, Cleveland Clinic Children's, Cleveland, OH
| | - Nouhad Raissouni
- Department of Pediatric Endocrinology, Cleveland Clinic Children's, Cleveland, OH
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24
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Noori S, McNamara P, Jain A, Lavoie PM, Wickremasinghe A, Merritt TA, Solomon T, Sekar K, Attridge JT, Swanson JR, Gillam-Krakauer M, Reese J, Poindexter BB, Brook M, Auchus RJ, Clyman RI. Catecholamine-resistant hypotension and myocardial performance following patent ductus arteriosus ligation. J Perinatol 2015; 35:123-7. [PMID: 25118721 PMCID: PMC4310792 DOI: 10.1038/jp.2014.151] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 06/05/2014] [Accepted: 06/16/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We performed a multicenter study of preterm infants, who were about to undergo patent ductus arteriosus ligation, to determine whether echocardiographic indices of impaired myocardial performance were associated with subsequent development of catecholamine-resistant hypotension following ligation. STUDY DESIGN A standardized treatment approach for hypotension was followed at each center. Infants were considered to have catecholamine-resistant hypotension if their dopamine infusion was > 15 μg kg(-1)min(-1). Echocardiograms and cortisol measurements were obtained between 6 and 14 h after the ligation (prior to the presence of catecholamine-resistant hypotension). RESULT Forty-five infants were enrolled, 10 received catecholamines (6 were catecholamine-responsive and 4 developed catecholamine-resistant hypotension). Catecholamine-resistant hypotension was not associated with decreased preload, shortening fraction or ventricular output. Infants with catecholamine-resistant hypotension had significantly lower levels of systemic vascular resistance and postoperative cortisol concentration. CONCLUSION We speculate that low cortisol levels and impaired vascular tone may have a more important role than impaired cardiac performance in post-ligation catecholamine-resistant hypotension.
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Affiliation(s)
- Shahab Noori
- Departments of Pediatrics of Children's Hospital of Los Angeles and University of Southern California, Los Angeles, CA,Departments of Pediatrics of University of Oklahoma, Oklahoma City, OK
| | - Patrick McNamara
- Departments of Pediatrics of Hospital for Sick Children, Toronto, Canada
| | - Amish Jain
- Departments of Pediatrics of Hospital for Sick Children, Toronto, Canada,Departments of Pediatrics of Mount Sinai Hospital, University of Toronto, Canada
| | - Pascal M. Lavoie
- Departments of Pediatrics of Children’s & Women’s Health Centre of British Columbia, Vancouver, Canada
| | - Andrea Wickremasinghe
- Departments of Pediatrics and Cardiovascular Research Institute, University of California San Francisco
| | - T. Allen Merritt
- Departments of Pediatrics of Loma Linda University, Loma Linda, CA
| | - Tabitha Solomon
- Departments of Pediatrics of Loma Linda University, Loma Linda, CA
| | | | - Joshua T. Attridge
- Departments of Pediatrics of University of Virginia, Charlottesville, VA
| | | | | | - Jeff Reese
- Departments of Pediatrics of Vanderbilt University, Nashville, TN
| | | | - Michael Brook
- Departments of Pediatrics and Cardiovascular Research Institute, University of California San Francisco
| | | | - Ronald I. Clyman
- Departments of Pediatrics and Cardiovascular Research Institute, University of California San Francisco
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25
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Clyman RI, Wickremasinghe A, Merritt TA, Solomon T, McNamara P, Jain A, Singh J, Chu A, Noori S, Sekar K, Lavoie PM, Attridge JT, Swanson JR, Gillam-Krakauer M, Reese J, DeMauro S, Poindexter B, Aucott S, Satpute M, Fernandez E, Auchus RJ. Hypotension following patent ductus arteriosus ligation: the role of adrenal hormones. J Pediatr 2014; 164:1449-55.e1. [PMID: 24636853 PMCID: PMC4035426 DOI: 10.1016/j.jpeds.2014.01.058] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 12/16/2013] [Accepted: 01/28/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that an impaired adrenal response to stress might play a role in the hypotension that follows patent ductus arteriosus (PDA) ligation. STUDY DESIGN We performed a multicenter study of infants born at <32 weeks' gestation who were about to undergo PDA ligation. Serum adrenal steroids were measured 3 times: before and after a cosyntropin (1.0 μg/kg) stimulation test (performed before the ligation), and at 10-12 hours after the ligation. A standardized approach for diagnosis and treatment of postoperative hypotension was followed at each site. A modified inotrope score (1 × dopamine [μg/kg/min] + 1 × dobutamine) was used to monitor the catecholamine support an infant received. Infants were considered to have catecholamine-resistant hypotension if their greatest inotrope score was >15. RESULTS Of 95 infants enrolled, 43 (45%) developed hypotension and 14 (15%) developed catecholamine-resistant hypotension. Low postoperative cortisol levels were not associated with the overall incidence of hypotension after ligation. However, low cortisol levels were associated with the refractoriness of the hypotension to catecholamine treatment. In a multivariate analysis: the OR for developing catecholamine-resistant hypotension was OR 36.6, 95% CI 2.8-476, P = .006. Low cortisol levels (in infants with catecholamine-resistant hypotension) were not attributable to adrenal immaturity or impairment; their cortisol precursor concentrations were either low or unchanged, and their response to cosyntropin was similar to infants without catecholamine-resistant hypotension. CONCLUSION Infants with low cortisol concentrations after PDA ligation are likely to develop postoperative catecholamine-resistant hypotension. We speculate that decreased adrenal stimulation, rather than an impaired adrenal response to stimulation, may account for the decreased production.
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Affiliation(s)
- Ronald I. Clyman
- Departments of Pediatrics and 1Cardiovascular Research Institute, University of California San Francisco
| | - Andrea Wickremasinghe
- Departments of Pediatrics and 1Cardiovascular Research Institute, University of California San Francisco
| | | | - Tabitha Solomon
- Department of Pediatrics, Loma Linda University, Loma Linda, CA
| | - Patrick McNamara
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Amish Jain
- Department of Pediatrics, Hospital for Sick Children, Toronto, Canada
| | - Jaideep Singh
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Alison Chu
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Shahab Noori
- Department of Pediatrics, University of Oklahoma, Oklahoma City, OK
| | | | - Pascal M. Lavoie
- Department of Pediatrics, Children’s & Women’s Health Centre of British Columbia, Vancouver, Canada
| | | | | | | | - Jeff Reese
- Department of Pediatrics, Vanderbilt University, Nashville, TN
| | - Sara DeMauro
- Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Sue Aucott
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Monique Satpute
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Erika Fernandez
- Department of Pediatrics, University of New Mexico, Albuquerque, NM
| | - Richard J. Auchus
- Department of Pediatrics, Department of Medicine, University of Michigan, Ann Arbor, MI
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26
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Besnier E, Clavier T, Castel H, Gandolfo P, Morin F, Tonon MC, Marguerite C, Veber B, Dureuil B, Compère V. [Interaction between hypnotic agents and the hypothalamic-pituitary-adrenocorticotropic axis during surgery]. ACTA ACUST UNITED AC 2014; 33:256-65. [PMID: 24631003 DOI: 10.1016/j.annfar.2014.01.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/27/2014] [Indexed: 01/07/2023]
Abstract
During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.
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Affiliation(s)
- E Besnier
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - T Clavier
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - H Castel
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - P Gandolfo
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - F Morin
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - M-C Tonon
- Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France
| | - C Marguerite
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - B Veber
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - B Dureuil
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France
| | - V Compère
- Département d'anesthésie-réanimation chirurgicale - SAMU, CHU de Rouen, 1, rue de Germont, 76031 Rouen, France; Inserm U982, DC2N Laboratory of Neuronal and Neuroendocrine Cell Differentiation and Communication, Astrocyte and Vascular Niche, IRIB, University of Rouen, PRES Normandy, 76821 Mont-Saint-Aignan, France.
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