A 55 year old male underwent coroanry artery bypass grafting and had an uneventful recovery in ICU. On post operative day 2, the pacing wire was removed.

Two hours after removal, the following are seen.

Vital Signs: SpO2 95% on FIO2 100%, HR 96, BP 85/44 on levophed 0.04 mcg/kg/min

Physical Examination: Jugular venous distension, muffled heart sounds and bilateral crackles on auscultation

Labs: Arterial blood gases: 6.9/66/57/ base excess -17 on FIO2 100%, mixed venous oxygen 21