LAUSR

A man in his 60s presented to an outside hospital with worsening shortness of breath over the preceding 6 months. He was hospitalized with atrial fibrillation with rapid ventricular response, and he experienced cardiac arrest requiring defibrillation and multiple doses of epinephrine. His vital signs on transfer to our ICU were temperature, 36.3 C; heart rate, 50 beats per minute; and BP, 90/50 mm Hg on 20 mg/min on norepinephrine. His ventilator settings were volume control rate of 16; tidal volume of 360 mL, positive end-expiratory pressure of 5, and FIO2 of 1.0. On physical examination he was sedated, with a 2/6 systolic murmur and decreased S1/S2 heart sounds. Pitting edema was present in all extremities, and his skin was cool to the touch. His laboratory examinations were remarkable for a WBC count of 14.7 10/mL, creatine level of 2.8 mg/dL, aspartate aminotransferase level of 7,000 units/L, international normalized ratio of 5.7, and