title: Adrenal insufficiency--an unusual cause of shock in postoperative patients.
abstract: OBJECTIVE
  To remind physicians that adrenal insufficiency can cause postoperative shock and that the manifestations are difficult to distinguish from those of sepsis.
  
  
  METHODS
  We present detailed case reports of three patients who had hyperdynamic shock in the surgical intensive-care unit and describe their response to the cosyntropin stimulation test.
  
  
  RESULTS
  All three patients were diagnosed as having adrenal insufficiency with use of the cosyntropin stimulation test. Two of the three patients rapidly recovered; however, because of delay in the diagnosis of adrenal insufficiency, the third patient succumbed to multisystem organ failure.
  
  
  CONCLUSIONS
  The cases presented highlight the need to exclude adrenal insufficiency as a possible cause of hyperdynamic circulatory shock, particularly when no clear-cut diagnosis exists. Early recognition of adrenal insufficiency is important and can result in reversal of shock and prevention of death. Adrenal insufficiency can be diagnosed through screening random cortisol levels and by use of the cosyntropin stimulation test. Patients in addisonian crisis often respond to the first dose of glucocorticoid with dramatic improvement in blood pressure and systemic vascular resistance. Administration of glucocorticoid can thus lead to improved organ perfusion and recovery of organ function. Delays in diagnosis and treatment of acute hypoadrenalism can have a fatal outcome.
authors.affiliation: Department of Surgery, Johns Hopkins Medical Institutional and Sinai Hospital of Baltimore, USA.
authors.forename: P
authors.initials: P
authors.lastname: Sabharwal
authors.forename: R S
authors.initials: RS
authors.lastname: Fishel
authors.forename: M J
authors.initials: MJ
authors.lastname: Breslow