The Real-World Boards: Question #23
A 42-year-old man with post-op respiratory failure and worsening fevers
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A 42-year-old man has been admitted to your ICU with a diagnosis of sepsis after an abdominal catastrophe. Home medications included aspirin, clonazepam, and sertraline. He presented with fever and abdominal pain and was taken from the E.D. to the O.R., where an exploratory laparotomy was performed, and a perforated gastric ulcer was repaired with a Graham patch. Broad-spectrum antibiotics were provided.
Despite fluid resuscitation, he remained slightly hypotensive, and low-dose norepinephrine was infused. He was kept intubated postoperatively due to his general instability.
Upon arrival to the ICU one hour ago, his vitals and gas exchange were nearly normal, on 5 mcg/min of norepinephrine. Urine drug screen is negative. TSH is normal.
You are called to his bedside because he “looks bad now.” You note that his pCO2 is 65 mmHg and pH 7.15, despite a minute ventilation of 14 liters, a temperature of 39.1°C, and a heart rate of 125, with worsening hypotension requiring an increase in norepinephrine to 20 mcg/min. His four limbs are rigid (equally), but his abdomen is relatively soft and is not distended. Lorazepam 2 mg IV has been given twice in the past 10 minutes without any change in the muscular rigidity.
