J.N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for...

J.N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for an acutely ischemic bowel. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic BP dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of 0.9% saline were infused. His pulmonary status worsened within 12 hours of admission to the ICU, requiring an emergent ET intubation. He developed a pneumothorax after intubation and a left-side chest tube was placed at that time. His hypoxemia has rapidly progressed and is currently refractory to 100% FIO2 and high levels of PEEP. His laboratory test results indicate kidney and liver failure. He has an advance directive that indicates he does not want to be kept alive by artificial means, but he has a full code status. He is currently sedated, paralyzed, and unable to communicate. his urinary catheter is draining concentrated urine <30 mL/hr. He has a central line in place and is receiving 0.9% saline at 125 mL/hr. His most recent ABGs are as follows: pH 7.12, PaO2 50 mm Hg, PaCO2 62 mm Hg, HCO3 17 mEq/L, and O2 saturation 84%. His PaO2/FIO2 ratio is <200 and his chest x-ray shows worsening bilateral interstitial infiltrates compatible with ARDS pattern.

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