ICU stories: 65 yo pt, fairly healthy besides HTN & an episode of diverticulitis 3 y ago, is brought to the ED due to 2 wks' hx of abd pain & 1 d hx of N/V ("coffee-ground"). Looked "bad". SBP in 60s - improved to 80s w ivf. Intubated. Had CT A/P 👇:
While you review the CT images, you get the lab results: Lactate 10, WBC 3K, INR 2.0, BUN/Creat 100/3.0, CRP 500 mg/l, Procalcitonin 300. The ED is calling you for the admission. What consult(s) do you ask?
The CT A/P showed a large amount of free intra-peritoneal air; stomach & SB were mildly distended & partially fluid-filled. There was colonic diverticulosis without diverticulitis & mild wall thickening involving the descending colon & the sigmoid colon
Obviously, GenSurg consulted (don't bother GI for perf viscus). Pt arrived to the ICU on norepi 0.4 & vaso 0.05. Already received 1 dose of ampicillin/sulbactam in the ED & total 4 lt of NS. Surgeon wants the patient to be "more stable" before taking him to OR. What do you do?
This is a common scenario; the surgeon (or the interventionalist, eg GI) wants the patient to be "stable" but in some cases this cannot be achieved without surgery. Common sense discussions between ICU & GenSurg usually lead to the appropriate course of action
In this case, pt went for emergent exploratory laparotomy. The colon / SB / stomach and liver were ischemic. Underwent resection of the ileum, the R colon & the proximal transverse colon. The abdomen was left open. Pt returned to ICU - repeat labs: lactate 18, WBC 1.5k
Progressed to multiorgan failure & next am family decided to "pursue comfort care". After your discussion w family about goals of care, the nurse informed you that the blood cultures from the previous night (14 hours ago) were positive. What do you think they grew?
Who expected these 👇? 
There is a widespread belief that community-acquired intra-abdominal infections need only a good surgeon & a sprinkle of ampicillin/sulbactam. This is not always the case even in patients that are not immunocompromised & have no frequent contact with health care facilities
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