Bladder pressure measurement is the most appropriate next step in management. Abdominal compartment syndrome (ACS) should be suspected in patients with oliguria or increasing serum creatinine levels who have had abdominal surgery, who have received massive fluid resuscitation, who have a tense abdomen, or who have liver or pancreatic disease with ascites. ACS is typically defined as new organ dysfunction with an intra-abdominal pressure >20 mm Hg. This patient is developing ACS manifested by increased hemodynamic instability, worsening respiratory failure with increased airway pressures and increasing difficulty with oxygenation, a tense abdomen on examination, and oliguric kidney failure. Diagnosis of intra-abdominal hypertension and ACS is accomplished by transduction of bladder pressure. Although medical treatment (diuresis, dialysis, management of ascites) can be tried, surgical decompression of the abdomen is often necessary to definitively treat ACS.

There are no data to support that transfusing patients with severe sepsis to a hemoglobin level above 10 g/dL (100 g/L) improves outcomes. The current Surviving Sepsis Guidelines recommend that, once tissue hypoperfusion has resolved and in the absence of serious comorbidities, erythrocytes should only be transfused when hemoglobin decreases to <7.0 g/dL (70 g/L).

Although this patient's urine sodium is <10 mEq/L (10 mmol/L), clinically he is not intravascularly volume depleted. Therefore, further volume resuscitation is not indicated because it may contribute to worsening organ dysfunction by increasing intra-abdominal pressure.

There is no evidence that hemodynamic monitoring with a pulmonary artery catheter improves clinical outcomes in patients with acute respiratory distress syndrome, and it may be associated with harm.