Impact of Adrenal Function on Hemostasis/Endothelial Function in Patients Undergoing Surgery
Abstract Context Glucocorticoids regulate hemostatic and endothelial function and are critical for adaptive functions during surgery. No data regarding the impact of adrenal function on hemostasis and endothelial function in the perioperative setting is available. Objective We assessed the association of adrenal response to adrenocorticotropic hormone (ACTH) and markers of endothelial/hemostatic function in surgical patients. Design Prospective observational study. Setting Single center study, tertiary care hospital. Patients 60 patients (35 male/25 female) undergoing abdominal surgery. Main Outcome Measures Adrenal function was evaluated by low-dose ACTH-stimulation test on the day before, during and the day after surgery. According to their stimulated cortisol level (cut-off ≥500nmol/L) patients were classified having normal HPA-axis function (nHPA) or deficient HPA-axis function (dHPA). Parameters of endothelial function (soluble vascular cell adhesion molecule-1 [sVCAM-1], thrombomodulin [TM]) and hemostasis (fibrinogen, von Willebrand factor-antigen [vWF], factor VIII [FVIII]) were measured during surgery. Results 21 had dHPA and 39 had nHPA. Compared to nHPA, Patients with dHPA had significantly lower peak cortisol before (median 568 vs. 425 nmol/L, p <0.001) and during (693 vs. 544 nmol/L, p <0.001) surgery and lower postoperative hemoglobin levels (116 g/L vs. 105 g/L, p=0.049). FVIII was significantly reduced in patients with dHPA in uni- and multivariable analyses, other factors displayed no significant differences. Coagulation factors/endothelial markers changed progressively in relation to stimulated cortisol levels and showed a turning point at cortisol levels between 500-600 nmol/L. Conclusions Patients with dHPA undergoing abdominal surgery demonstrate impaired hemostasis which can translate into excessive blood loss.