They're going to gradually reduce the anesthetic rather than waking him up all at once; it'll let them more smoothly titrate the doses of vasopressors, and they could use another half-hour of image sequences to monitor and make sure nothing goes wrong in there, and finish calibrating the exact concentration of various solutes and drugs in the bowel prep. And it'll let them figure out pain control as they go, optimizing for an epidural dose that's enough to keep Kalorm comfortable without a lot of systemic pain medication, but not high enough to have major effects on his blood pressure. 

...Also they'll place the rectal tube now, even though nothing is really draining yet. It should be reasonably comfortable and non-obtrusive once it's in place, but getting in there - especially without risking causing any damage - is a lot simpler when their patient is still out. 

There's still nothing in it half an hour later, when they have the sedation reduced to 'moderate'. Kalorm is now responding slightly to painful stimuli, and breathing above the set rate on the ventilator; they've had the oxygen set at 25% the whole time and settings barely above the minimum. 

They've been having a time weaning the high doses of vasopressors, though. It's taken them this long just to wean him off the epinephrine; he's still at the maximum rate of the other one. 

This is mildly worrying but there's not really anything to do other than keep monitoring him. Can Merrin come be nearby while they wake him the rest of the way? 

Yeah, of course. 

It's past 3:30 pm. Merrin isn't normally tired this long into a shift, and she mostly hasn't even been doing stuff for the last two hours, but apparently STRESS is really exhausting. She keeps obsessively refreshing Diagnostics even though the time estimate on finalized pathology and lab results is another 40 minutes. She wants to be HOME back in her nice safe familiar ICU. 

She holds Kalorm's hand and quietly talks to him while the anesthesiologist pauses the sedation. 

Initially - and for long minutes - he doesn't respond at all to her voice, though he makes a face and weakly tries to pull away when she pinches his nail. He's also starting to shiver slightly; it's pretty common for a patient's body temperature to drop a little while they're under anesthetic, but the air temperature is warm and the bed mattress is set to heating mode. His body temperature is 36.5, which isn't especially low for him. 

Merrin can get him an electric blanket, but she's faintly worried. He isn't running a fever - yet - but something about how he looks is bothering her. 

She watches the EEG tracing and keeps talking to him, repeating reassurance that the diagnostics are all done and he's doing fine and can he squeeze her hand please. 

It's a faster wakeup than the last time they weaned Kalorm's sedation. Within five minutes, his eyelids are flickering (and he's starting to gag on the breathing tube). Another minute or so after that, he manages to squeeze Merrin's hand. 

"Hey, welcome back to the world of the conscious!" Merrin squeezes his hand back. "Can you open your eyes all the way? I think we need you a little more awake than this before we can pull the tube." 

Kalorm seems to spend a while trying this, but eventually manages to peel his eyelids open and direct a very tired eye-roll at the ceiling. 

"There you go! Okay, I need you to take a deep breath and cough..." 

Kalorm is still clearly pretty groggy, responding to instructions only on a five or ten second delay, but his cough is reasonably strong and he can manage to keep his eyes open, if not with much enthusiasm.

They get his head elevated and suction his mouth clear before pulling the tube and placing an oxygen mask - at 35% concentration and a high flow rate, because he is still very drowsy - and get him settled comfortably on his side in a nest of pillows. 

(Kalorm sort of has to admit that the bed is way more comfortable than the floor.) 

Even with the lights on and people moving around him, he falls asleep again within thirty seconds. 

That seems fine. His oxygenation is great and he's probably exhausted. 

They hang out in the operating suite for another ten minutes, making sure his vital signs are going to stay stable and getting one last confirmation that his gut is tolerating the bowel prep solution without it causing any disasters and the rate of bleeding is stable, and then to Merrin's VAST RELIEF, they're going to trek back to the ICU and get him re-settled there. It's about four o'clock. 

Kalorm's eyes flicker open briefly when they reach the room, but he seems to have no particular interest in being awake yet. 

In that case Merrin is definitely not going to shake him awake to find out if he wants to immediately go back to his floorbed. She'll check Treatment Planning updates instead. 

The plan for the evening and night is roughly just to keep going with exactly what they're already doing - keeping his stomach decompressed via nasogastric tube, separately running the bowel prep solution to keep flushing everything out, potentially in addition to more enemas if the rectal tube isn't draining as much as they want, and then monitoring him incredibly closely. Kalorm is going to be pretty annoyed about it, because they want fresh ultrasound coverage of his gut every hour and they're going to haul him off for another radioisotope scan at midnight. They really don't have a better option than carrying on with their current plan and hoping Kalorm responds well to it, and then escalating as needed if he, instead, responds varying degrees of poorly to it. 

They're...not that confident he's going to respond well to it. They're only putting 55% that he gets through the night without deterioration or complications, and 20% that he ends up back in the OR before then. 

Reports are trickling in. They didn't find a detectable bacterial presence in his systemic bloodstream, but they did get a just-barely-positive result on gene sequencing in one of his mesenteric vein branches, and there are definitely gut-sourced bacteria in his lymph; they're waiting on cultures for more detail. The inflammatory markers are also insanely high; it's bad enough to start worrying about an inflammatory cascade causing clotting and microcirculatory dysfunction. The fluid they sampled from his duodenum definitely has bacterial colonization that shouldn't be there. And the biopsy tissue samples they took from his small intestine look pretty terrible! The epithelial level is shredded and a high fraction of the villi are damaged and partly disintegrating. 

They're pretty worried about the blood pressure variability. It's vaguely starting to look like early stages of sepsis, or at least a massive systemic inflammatory response with some of the same effects. 

On the bright side, his pain control seems entirely adequate right now? 

...Yeah, Merrin's definitely kind of worried that Kalorm looks like he might be starting to brew an infection, and even with the antibiotic coverage, that could get very bad very fast. 

She'll keep reading the updates and watching him sleep, and then at 5 pm, if he's still asleep, she's going to have to bother him and do an abdominal ultrasound. Maybe he'll sleep through it, given the epidural? Though she didn't explain in advance that she would have to do it, so ideally she would explain now rather than doing it without even asking him. 

Is there anything draining in the rectal tube yet? 

A little bit? Like 20 mls of sludgy stuff. 

Kalorm is dozing, not deeply asleep. He hears Merrin's voice saying his name as though coming from the surface of a deep warm pond, a long way off. He isn't especially interested in answering. 

"Sorry! I don't need you to wake up all the way, but I do need to take some more ultrasound images of your belly and make sure things are okay in there. And would be good to get a yes-or-no on whether you're in pain right now?" 

....Somewhat surprisingly, no? Kalorm manages to find the energy to shake his head. 

"Good. Uh, if you're still this sleepy in an hour I'm going to start to worry, but you're probably still clearing out the anesthesia, you can nap." 

How does everything look on the ultrasound? 

Things are moving! This was actually already clear from the fact that the large-bore nasogastric tube is draining substantially less, and the contents are clearer, more gastric juices with less backed-up bile. The weight on the end of the feeding tube is clearly visible on the ultrasound; it's harder to follow the coils of small bowel below that, but at a guess, the next fifty centimeters or so are managing reasonable peristalsis. 

The bottom end of things is also looking better! It's taking a while for the irrigation fluid they instilled during the OR procedure to fully work its way down with the other intestinal contents, but it seems to at least be in the process. 

The lower half of his small intestine is NOT looking better. It's hard to judge for sure if it's more swollen and distended with gas and fluid, but it looks like it. 

Merrin is not delighted about this! It's not an emergency (yet) but it's not an update in the direction she was hoping! 

She gets Kalorm tucked in again, takes a couple of steps back from the bed, and looks him over. 

He doesn't look awful? 

His oxygen saturation is at 100% - but even asleep and apparently relaxed, he's breathing at 19 a minute. His heart rate is at 85, which isn't objectively worrying but is highish for him - and he's still on a moderate dose of vasopressors, around 50% of the maximum rate, to maintain a blood pressure of 100/60. He's no longer shivering - but despite the warming blanket and bed set to heating mode, his temperature is still 36.2 C. 

His feet, when she lifts the blanket to check them, feel cold. Which isn't a first, his feet just get cold sometimes, but this time the capillary refill is mildly but noticeably delayed. 

Dislike!!!!!!!! 

[I want to get another set of labs] she subvocalizes to the command center. [Is there anything we can do to bring down the inflammatory response without risking knocking out his immune system?]

She almost wishes they could just trust the antibiotics and knock out his immune system anyway and at least prevent his own body from causing a new set of organ damage, but that could in fact go really badly! 

They're considering it! There's probably a best option here that gets them the most of the value with the least downside risk. It's not super obvious - the immune system is complicated, not entirely understood even by dath ilan science, and varies significantly between people - but they're throwing some more modeling at it and digging up more case studies. 

In the meantime they want another liter of IV fluids. It's likely that he's oozing fluid into his tissues, through increasingly permeable capillaries, and while that isn't ideal, they still need to keep enough volume in his bloodstream.