A 57-year-old male patient develops confusion and lethargy in the intensive care unit. He is 4 days status post emergent surgery for a perforated gastric ulcer that developed as a result of daily nonsteroidal anti-inflammatory drug (NSAID) use for chronic lower back pain. He was treated with an exploratory laparotomy and an omental (Graham) patch closure of the ulcer. On physical examination, his temperature is 39.2 °C, heart rate is 96 beats per minute, respiratory rate of is 24, and blood pressure is 82/62 mmHg. Oxygen saturation is 92% on room air. The surgical incisions appear clean and intact, and the abdomen is nontender. There are diminished breath sounds on the right. His urine output has been 10 cc for the last 6 hours, and the urine appears dark. Laboratory values reveal a white blood cell count of 18 × 103/μL (normal 4.1–10.9 × 103/μL), serum creatinine of 3.2 mg/dL (from a baseline of 1.1 three days earlier), and a blood pH of 7.1. Chest x-ray demonstrates a large area of consolidation in the right lower lobe. Given his lethargy, tachypnea, and low oxygen saturation, he is intubated by way of rapid sequence intubation. He is given several IV fluid boluses; however, the blood pressure does not improve. Vasopressors are initiated. Blood cultures are sent.
- Critically ill