72 Hours Post-ICU Admission

Over the next 24 hours, despite maximal support, the patient continues to deteriorate. He remains intubated, anuric, coagulopathic, and hypotensive.

Current supports:

• Intubated, FiO₂ 1.0, PEEP 14, SpO₂ 84%
• Norepinephrine 0.5 mcg/kg/min
• Vasopressin 0.04 U/min
• Hydrocortisone on board
• Meropenem + caspofungin started empirically
• Platelet transfusion, cryoprecipitate, and FFP given
• RRT not yet initiated due to INR 2.4 and platelet 38k

New findings:

• GCS 3T (deeply sedated)
• MAP fluctuating 55–60 mmHg despite dual vasopressors
• Lactate: 6.3 mmol/L
• ABG: pH 7.12 / PaCO₂ 42 / PaO₂ 56 / HCO₃⁻ 13
• Total bilirubin: 5.1 mg/dL, AST/ALT worsening
• New fixed dilated pupils, sluggish response
• CT brain: diffuse cerebral edema, loss of sulcal pattern, early tonsillar herniation
• Repeat echo: EF 65%, CO 3.2 L/min
• Family present, distressed; wife asks: “Is he going to survive?”

Questions

1. What is the likely cause of the neurological findings? Is it reversible?
2. What are the criteria for brain death testing, and can it be performed now in this case?
3. Would you initiate RRT now? Justify your decision.
4. Would you consider escalation (e.g., 3rd vasopressor, ECMO)? Why or why not?
5. How would you approach communication with the family regarding prognosis and decisions ahead?
6. If family asks for full support “at any cost,” how would you respond while remaining ethically sound and compassionate?