Abstract
A 53-year-old male is admitted to the intensive care unit (ICU) from the emergency department (ED) with a diagnosis of pneumonia and septic shock. In the ED he was hemodynamically unstable and received a total of 9 liters of intravenous (I.V.) fluids to raise his CVP (central venous pressure) to 12 mm Hg. He was started on a norepinephrine infusion titrated to maintain a mean arterial pressure (MAP) of greater than 60 mm Hg. On arrival in the ICU he remains unstable with MAPs in the low 60s with a CVP of 18 mm Hg, poor urinary output and increasing peak inspiratory pressures (PIPs) (greater than 35 cm H2O). What do you suspect?