Acute adrenal insufficiency is a rare complication that can manifest in the perioperative period. The most common cause is exogenous steroid administration (tertiary adrenal insufficiency) resulting in atrophy of the adrenal cortex due to insufficient ACTH release from the pituitary gland, and the subsequent inability to produce endogenous glucocorticoids. Rarer causes of adrenal insufficiency are Addison's disease (primary adrenal insufficiency), which results in absence of all endogenous steroid production, as well as pituitary and hypothalamic tumors or lesions (secondary adrenal insufficiency). It should be noted that patients with Addison's disease are at higher risk for developing acute adrenal insufficiency due to a lack of both glucocorticoid and mineralcorticoid production.
Preoperatively, this is a diagnostic dilemma for clinicians. In cases of tertiary adrenal insufficiency, a history of exogenous steroid use within the past 3 months is a useful history to elicit. For primary and secondary presentations, the patient may manifest non-specific symptoms like nausea, vomiting, weight loss, and increased skin pigmentation. Electrolyte abnormalities like hypoglycemia, hyponatremia and hyperkalemia may be found on chemistries. However, most patients may be asymptomatic until the perioperative period when hypotension unresponsive to vasopressor and fluid support presents itself.