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A 60 year old man with atrial fibrillation, cirrhosis, adrenal insufficiency, and coronary artery disease presents with a severe pneumonia. He is intubated for hypoxemic respiratory failure and admitted to the intensive care unit. His blood pressure is 100/40, heart rate 110, and temp 101. Early goal directed therapy is initiated, and he is bolused 5L crystalloid and started on norepinephrine. His ventilator settings are tidal volumes 400, rate 16, PEEP 5, PS 10, FiO2 50% with SpO2 96%. His CXR shows a multilobar consolidation. His coumadin, propranolol, and ASA are held. Labs show WBC 20,000, hematocrit 12, platelets 40,000, creatinine 1.0, and INR 2.8. His current medication list is: dexmedetomidine drip, hydromorphone drip, norepinephrine drip, albuterol/ipratropium, hydrocortisone, vancomycin, piperacillin-tazobactam, levofloxacin, insulin as needed, lactulose, and subcutaneous heparin. He is kept NPO. On hospital day 3, he drops his hematocrit to 9. An upper endoscopy shows shallow mucosal oozing in the fundus and body of the stomach.

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