POMC and acute adrenal insufficiency: Perioperatively, patients with adrenal crisis present with an unexplained shock that is refractory to vasopressors and fluids associated with hyponatremia, hyperkalemia, hypoglycemia, low or low normal ACTH level in secondary adrenal insufficiency and high or high normal ACTH level in primary adrenal insufficiency, hypercalcemia, prerenal failure with elevated creatinine level, and low aldosterone.