I haven't been in SICU that long, but recently I had the sickest pt I've ever had helping out on a 2:1. He had a MVR/AVR and dropped his pressures in the OR so they gave epi and he developed "stone heart" (cramped heart) and dropped his pressure to almost nothing. So they put in a IABP but that didn't really seem to help so the surgeon put in a LVAD. So this pt has been sitting in SICU for the last 4 days on 40 of LeVo, maxed out Vaso, 5 of dopa, high dobut, diprivan, lasix, insulin, getting a-line MAPs of 59 and IABP pressure 55/50 with aug of 60. The day before he had a LBBB for his underlying rhythm so we paused to check it out and he was asystole (sweet....). The perfusionist turned off his LVAD and we turned his IABP to 1:3 from 1:1 with no perfusion on the a-line except the little bump on every third beat from the IABP. CVP was anywhere from 10-15 with a PA of low 20's/low teens. I shot a index just for fun and it was 1.1 with CO of 2.9 (which just happened to be the same flow as the LVAD... :-/) SVR like 900. He was bleeding out just about everywhere; IABP (d/t difficult placement/cutdown), cordis, CT, PICC, etc. We were checking Hgb every 1-2 hrs and just dumping in blood. Couldn't get it above 8. CT was putting out around 400 an hour. His ABGs were fine. Coags weren't terrible 1.5 INR and a little low on her fibrinogen. Gave her some FFP for that. I'm wondering how long you all have seen MDs keep someone like this on the LVAD. It's not like he was getting better or getting worse. I would've thought she would be getting acidotic by now if hewas going to go in the wrong direction. The rest of his body wasn't bad. Vent was SIMV 10 TV 600 PEEP 5 on 50% FiO2(was 30% but I guess RT isn't supposed to put FiO2 lower than 50 with an LVAD).