Hormonal responses to surgical stress in children

doi:10.1016/S0022-3468(05)80343-4

Journal of Pediatric Surgery

Volume 28, Issue 1, January 1993, Pages 1-4

https://doi.org/10.1016/S0022-3468(05)80343-4 Get rights and content

The hormonal responses to surgical stress in adults are well characterized. We hypothesized that children have age-related differences in the “stress responses” to surgery. To test this hypothesis we prospectively studied 98 children (aged 2 to 20 years) undergoing elective surgical procedures under general anesthesia. Preoperative and postoperative (1 hour postoperation) blood samples were obtained and serum prolactin and cortisol concentrations were measured. Patient data were stratified by patient age and length of operation. All patients had significant (P<.05) increases in serum cortisol and prolactin concentrations 1 hour postoperatively as compared with preoperative values. However, there were no significant differences in prolactin and cortisol responses to surgery based on the age, anesthetic technique, or length of operation. Females had higher mean (±SD) serum prolactin concentrations (78.41±62.23 μg/L) as compared with males postoperatively (39.8±21.75 μg/L) (P<.05). We conclude the following: (1) children have significant increases in circulating prolactin and cortisol concentrations following surgery and anesthesia, and that those increases are not affected by age, length of surgery, or anesthetic technique; and (2) females have greater prolactin responses to surgery and anesthesia than males.

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Effects and mechanisms of perioperative medications on the hypothalamic pituitary adrenal response to surgical injury: A narrative review
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The adrenal gland is a vital endocrine organ, and adrenal steroid synthesis and secretion are closely regulated by the hypothalamic–pituitary–adrenal (HPA) axis in response to various stimuli. Surgery or trauma can activate the HPA axis and induce the secretion of cortisol. Different cortisol responses vary with the grade of surgery. Perioperative medications have the potential to decrease the cortisol level in the body, and both excessive and insufficient cortisol levels after surgery are disadvantageous. The effect of perioperative medications on the HPA response to surgery can be divided into three levels: “adrenal insufficiency (AI)”, “stress response inhibition”, and “uncertainty”. The clinical presentation of AI includes fatigue, nausea, vomiting, abdominal pain, muscle cramps, hypotension, hypovolemic shock and prerenal failure, which may result in fatal consequences. Stress response inhibition can reduce postoperative complications, such as pain and cognitive dysfunction. This is protective to patients during perioperative and postoperative periods. The aim of the present review is to shed light on current evidence regarding the exact effects and mechanisms of perioperative medications on the HPA response to surgical injury and provide the applicable guidance on clinical anesthesia.
Local anesthetic added to spinal anesthesia; does it stabilize stress hormones after inguinal herniorrhaphy?: A randomised controlled trial
2021, International Journal of Surgery Open
Citation Excerpt :
In a prior study among children who underwent inguinal hernia repair author implied on that general anesthesia (GA) could not be preventable for postoperative increase in cortisol and prolactin plasma level. They also concluded that plasma concentrations of the latter hormones were independent factor from age, duration, and technical approach of surgery [12–14]. Similarly other author stated that plasma levels of both cortisol and prolactin have increased postoperatively following the GA in case of inguinal hernia repair [15].
Elective inguinal hernia repair is a common minor surgery. Early postoperative mobilization without inflammatory related complication is desired.
In this randomized controlled trial study 48 adult males were enrolled who experienced elective inguinal hernia repair under spinal anesthesia. Subjects were categorized in 2 groups with equal 24 members in each including patients received local anesthetic (2 mg kg⁻¹ of bupivacaine 0.5%) in addition to spinal anesthesia and controlled who had spinal anesthetic with local placebo injection. Plasma cortisol and prolactin concentration were obtained 1 h before and 3 h after operation. To evaluate severity of postoperative pain the visual analogue scale(VAS) was applied. We also measured the total dosage of analgesic requirement among patients.
Data showed that spinal anesthesia alone was followed by increasing plasma concentration of either cortisol or prolactin postoperatively (P < 0.01). Findings according to investigate severity of pain implied on that local anesthesia could make more postoperative comfort for patients with inguinal herniorrhaphy(P < 0.001). Therefore, analgesic requirement in patients who were equipped by additional local anesthesia also decreased(P < 0.001).
We concluded that adding local anesthetic to basic spinal anesthesia during inguinal herniorrhaphy could induce to either lower stress hormones plasma concentration or decrease pain and need for analgesic postoperatively.
Development of the HPA axis: Where and when do sex differences manifest?
2014, Frontiers in Neuroendocrinology
Sex differences in the response to stress contribute to sex differences in somatic, neurological, and psychiatric diseases. Despite a growing literature on the mechanisms that mediate sex differences in the stress response, the ontogeny of these differences has not been comprehensively reviewed. This review focuses on the development of the hypothalamic–pituitary–adrenal (HPA) axis, a key component of the body’s response to stress, and examines the critical points of divergence during development between males and females. Insight gained from animal models and clinical studies are presented to fully illustrate the current state of knowledge regarding sex differences in response to stress over development. An appreciation for the developmental timelines of the components of the HPA axis will provide a foundation for future areas of study by highlighting both what is known and calling attention to areas in which sex differences in the development of the HPA axis have been understudied.
The interaction of social risk factors and HPA axis dysregulation in predicting emotional symptoms of five- and six-year-old children
2012, Journal of Psychiatric Research
Citation Excerpt :
Luby et al. (2003a) found altered HPA axis reactivity in depressed preschool children indicated by a pattern of increased cortisol levels in response to separation and frustration stressors. Several studies point to stress-related cortisol responses also in younger children (Buske-Kirschbaum et al., 1997; Dahl et al., 1992; Gunnar et al., 2003; Hatzinger et al., 2007; Khilnani et al., 1993; Lundberg, 1983). In contrast to the findings of elevated cortisol reactions in children with emotional problems, recent studies demonstrated blunted cortisol reactions in children living in adverse environmental conditions.
We examined the links of social relational (family environment and peer victimization) and neuroendocrinological (HPA axis dysregulation) risk factors to children’s emotional symptoms. We placed special emphasis on the joint effects of these risk factors with respect to the emergence and course of the emotional symptoms.
One hundred and sixty-six children were interviewed (Berkeley Puppet Interview) at age 5 and 6. Teachers and parents completed the Strengths and Difficulties Questionnaire. Parents completed the Family Environment Scales. Peer victimization was assessed by teacher and child reports. Children’s saliva cortisol was measured before and after a highly structured story completion task which targeted their cognitive emotional representations of family conflicts.
In the cross-sectional analyses, negative family environment, peer victimization, and cortisol increase during the story completion task independently contributed to the variance of emotional symptoms. There was a significant interaction effect between family environment and cortisol increase: those six-year-olds who had experienced an unfavorable family environment only showed high levels of emotional symptoms if they exhibited a cortisol increase during the story completion task. In the longitudinal analysis, peer victimization at age 5 predicted an increase of emotional symptoms at age 6, but only for those children who exhibited a blunted cortisol response a year earlier.
Negative family environment and peer victimization proved to be independently associated with emotional symptoms. HPA axis reactivity differentially moderated these associations. Therapeutic strategies should take the interaction between negative relational experiences and biological susceptibility to stress into account.
Psychosocial stress exposure impairs memory retrieval in children
2012, Psychoneuroendocrinology
Citation Excerpt :
As expected, no significant differences were observed for passive storage (forward tests) or immediate recall. In line with our results, the successful elicitation of the HPA axis in response to the TSST-C or to slightly modified versions of it has been reported in 7- to 14-year-old participants (Khilnani et al., 1993; Buske-Kirschbaum et al., 1997, 2003; Yim et al., 2010b; Quas et al., 2011). Taken together, these findings contradict the idea of a stress hyporesponse period during childhood (reviews in Gunnar and Cheatham, 2003; in Lupien et al., 2009) and suggest that social-evaluative threat activates the HPA axis in children and adults alike (Dickerson and Kemeny, 2004).
Negative consequences of stress on working memory and delayed memory retrieval have been observed in adult humans. Little is known about the occurrence of similar effects in children. Forty-four German full-term children, aged 8–10 years, were randomly assigned to a stressful (Trier Social Stress Test for Children – TSST-C) or to a non-stressful control condition. Afterwards, delayed memory retrieval was tested using a computerized version of the well-known card game “Memory”. It contained positive, neutral and negative stimuli. In addition, working memory of verbal and non-verbal material was assessed. The stressed children showed pronounced cortisol increases accompanied by a decrease in mood. Children exposed to the stressor performed poorer in the delayed memory retrieval test (memory card game). They committed more errors. No differences were found for working memory. The stress-induced memory retrieval impairment mirrors findings in adults. In contrast, the missing working memory effects could suggest developmental differences in stress sensitivity.
Salivary cortisol levels are associated with resource control in a competitive situation in 19month-old boys
2011, Hormones and Behavior
Citation Excerpt :
No association was detected between the frequency of crying and the capacity to control resource in the competitive situation for both girls and boys, suggesting that the association observed between resource control and cortisol in boys was not accounted for by sex differences in emotional distress. Sex differences in cortisol reactivity have already been documented in young adulthood (Kirschbaum et al., 1992) or in elderly subjects (Kudielka et al., 1998) exposed to a social stressor, but no apparent sex differences in children, a fortiori in toddlerhood, have been yet reported (Buske-Kirschbaum et al., 2003; Khilnani et al., 1993; Lundberg, 1983; Tout et al., 1998), which is in agreement with our results. As to emotional and social behaviors, several studies have looked at sex differences across childhood.
Glucocorticoids (GCs) have been related to social rank in many studies across species, a particular rank giving rise to a particular stress-related physiological profile. Our aim was to examine the hypothesis that GCs levels in toddlers would be related to social dominance in a competitive resource situation. Subjects were 376 toddlers from the Quebec Newborn Twin Study. At 19 months of age, each subject was exposed to 2 unfamiliar situations known to be moderately stressful at that age. Saliva was collected before and after the unfamiliar situations, to assess pre-test and reactive cortisol. Then the toddler reaction to a competitive situation for a toy with an unfamiliar peer was assessed and we measured the proportion of time the child controlled the resource. In girls, no association between cortisol levels and the proportion of time the child got the toy was found. On the other hand, in boys, increased cortisol levels before the unfamiliar situation were significantly related to a decreased proportion of time they got the toy in the competitive situation (r₁₇₄ = − 0.17, P = 0.02). These results show that even in toddlers with limited social experience, association between GCs levels and social dominance can be found, an association that is specific to boys.

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^†: Supported in part by funds from the Henry K. Beecher Memorial Anesthesia Research Laboratories at the Massachusetts General Hospital, Boston, MA.

¹: From the Departments of Pediatrics and Anesthesia (Critical Care), Harvard Medical School, Massachusetts General Hospital, Boston, MA.

View full text

Hormonal responses to surgical stress in children†

J Pediatr

Br J Anaesth

Br J Anaesth

J Pediatr Surg

Hormonal response to graded surgical stress

Arch Intern Med

Pituitary-adrenal response following trauma to the isolated leg

Surgery

Cortisol and growth hormone response to surgical stress during morphine anesthesia

Anesth Analg Curr Res

Endocrine responses to critical illness

Semin Respir Med

Hormonal and metabolic considerations in critical care medicine

Divergence in adrenal steroid secretory pattern after thermal injury in adult patients

J Clin Invest

A longitudinal evaluation of thyroid function in critically ill surgical patients

Ann Surg