This 28 year old man sustained a gunshot wound to the abdomen and arrived at the hospital in shock. He underwent repair of injury to his right iliac vein as well as multiple bowel injuries requiring resection. He received large volumes of crystalloid and blood during resuscitation. In the ICU, 36 hours after admission, he was noted to have abdominal distension. Over the next four hours he had progressive oliguria and hypoxia despite increasing pressure settings on the ventilator.