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A 77-year-old man is admitted to the intensive care unit (ICU) of a university hospital from the operating room. Earlier the same day, he had presented to the emergency department with abdominal pain. His medical history included treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment. In the emergency department, he was drowsy and confused when roused and was peripherally cold with cyanosis. The systemic arterial blood pressure was 75/50 mm Hg, and the heart rate was 125 beats per minute. The abdomen was tense and distended. After the administration of 1 liter of intravenous crystalloid to restore the blood pressure, a computed tomographic scan of the abdomen showed extraluminal gas and suspected extraluminal f***s consistent with a perforated sigmoid colon. He was treated with intravenous antibiotics and taken to the operating room for laparotomy. During this procedure, gross f***l peritonitis from a perforated sigmoid colon was confirmed; resection of the sigmoid colon with closure of the re**al stump and creation of an end colostomy (Hartmann’s procedure) was performed with extensive peritoneal toilet and washout.

On arrival in the ICU, he is still anesthetized, the trachea is intubated, and the lungs are mechanically ventilated with a fraction of inspired oxygen of 0.4; the arterial blood pressure is supported with a norepinephrine infusion. When the patient was in the operating room, he received a total of 4 liters of crystalloid. On his arrival in the ICU, the vital signs are a blood pressure of 88/52 mm Hg, heart rate of 120 beats per minute in sinus rhythm, central venous pressure of 6 mm Hg, and temperature of 35.6°C. An analysis of arterial blood shows a pH of 7.32, a partial pressure of carbon dioxide of 28 mm Hg, a partial pressure of oxygen of 85 mm Hg, and a lactate level of 3.0 mmol per liter.

A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment was admitted to the intensive care unit (ICU) of a university hospital after a resection of the rectosigmoid colon with closure of the re**al stump and formation of an end colostomy performed for f***l peritonitis caused by a perforated sigmoid colon.

Now we must deal with setting the patient’s ventilator. The patient is 178 cm tall and weighs 60 kg. On arrival in the ICU, he was hypotensive with a poor urine output. His arterial blood pressure has been supported with intravenous fluids and a norepinephrine infusion. After 24 hours in the ICU, he has a positive fluid balance of 2 liters.

Echocardiography shows normal left ventricular size and function, and a pulmonary-artery catheter shows that the pulmonary-artery occlusion pressure is 11 mm Hg. The patient is sedated and undergoing volume-cycled mechanical ventilation. Current ventilator settings are a tidal volume of 450 ml, a respiratory rate of 20 breaths per minute, a fraction of inspired oxygen (FiO2) of 0.6, and a positive end-expiratory pressure (PEEP) of 5 cm of water. Chest radiography shows bilateral diffuse alveolar infiltrates, current arterial blood gases are pH 7.25, the partial pressure of arterial oxygen (PaO2) is 74 mm Hg (9.8 kPa), the partial pressure of arterial carbon dioxide (PaCO2) is 55 mm Hg (7.3 kPa), and the plateau airway pressure (at a time of zero tracheal airflow) is 32 cm of water.

Case
A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment required 15 days of treatment in the intensive care unit (ICU) of a university hospital for septic shock due to f***l peritonitis from a perforated sigmoid colon. After surgery, he was placed on a mechanical ventilator. Complications during his ICU stay included mild disseminated intravascular coagulation and acute hepatic necrosis associated with acetaminophen treatment. After being transferred to the surgical floor, he had an unwitnessed fall from his bed, and cranial computed tomography showed an acute subdural hematoma with underlying hemorrhagic contusion on the left side and 5-mm displacement of the midline intracranial structures.

He was taken to the operating room and underwent a craniotomy for evacuation of the subdural hematoma. Twelve days after this procedure, during which he received no sedative medications, he remains in a coma with a best motor response of abnormal flexion on the left side. He is still receiving mechanical ventilation. The consensus opinion of treating clinicians is that he will most likely not make a functional recovery.

A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment is admitted to the intensive care unit (ICU) of a university hospital from the operating room after a Hartmann’s procedure (resection of the rectosigmoid colon with closure of the re**al stump and formation of an end colostomy) performed for f***l peritonitis due to a perforated sigmoid colon. After surgery, the patient undergoes mechanical ventilation with the use of a low-tidal-volume protocol with positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome and is treated for septic shock. Complications during his ICU stay include mild disseminated intravascular coagulation and acute hepatic necrosis caused by acetaminophen treatment. Despite active mobilization, a degree of ICU-acquired weakness has developed.
After 15 days in the ICU, the patient is weaned from mechanical ventilation and transferred to the surgical floor. On the third morning after discharge from the ICU, he is found on the floor of his room, having apparently fallen from his bed. On examination, he opens his eyes but is not able to speak coherently. He has decreased movement on the right side. His pupils are both midsized and reactive to light. Cranial computed tomography (CT) reveals an acute subdural hematoma in the left hemisphere with underlying hemorrhagic contusion and 5-mm displacement of the midline intracranial structures.