الفهرس 
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Abstract
During critical illness, the hypothalamic-pituitary-adrenal axis is activated, as demonstrated by increased serum corticotropin and cortisol concentrations. In most patients with adrenal insufficiency, determination of the response of the serum cortisol concentration to corticotropin is helpful in making the diagnosis. However, occult relative adrenal insufficiency, defined as a state in which corticosteroid administration diminishes or eliminates the requirement for vasopressor drugs, rather than as a state in which hypothalamic-pituitary-adrenal function is clearly abnormal, may occur in some critically ill patients. Patients receiving treatment with corticosteroids for chronic autoimmune or inflammatory diseases need less additional corticosteroid during severe illness and perioperatively than those receiving replacement therapy for hypothalamic-pituitary-adrenal insufficiency. Evaluation of adrenal function during critical illnesses is difficult because there are many controversies and a larger number of confounding factors. In some centers, critically ill, hypotensive patients are treated with glucocorticoids routinely without any input from endocrinologists to evaluate adrenal function. In many other centers, however, endocrinologists are consulted to evaluate adrenal function in these patients. Ideally, attempts should be made to identify patients at risk for adrenal impairment. In interpreting serum total cortisol levels, one should consider the limitations of these measurements when the binding proteins (transcortin and albumin) are increased or decreased.