He's beginning to get better, but according to your numbers he still need resuscitation, CVP low and a respectable base defeciet. 11 liters and some colloid. He looks like he has room for more fluid. Keep it going in the PACU/ICU where ever he's at now. But his heart is still puzzling, and its gonna need some more work up. If the fluid doesn't slow him down I'd go back to the esmolol which looks like it worked. Hopefully you can slow him down, increase his filling time, and bring his pressure up. Has anyone checked cardiac enzymes yet or an ECG when is rate was down? Has his bout of sepsis kicked him into an MI or at the least some demand ischemia? Smoker, late 40s, stays at home when he's this sick my guess is isn't well followed as an outpatient. New a-fib will probably need cardiology followup eventually. The big question my mind is, do you need it at one am. My guess is probably not. The only thing his a-fib needs right now is rate control. If your TEE savvy that's the easy answer. You can optimize his fluids a little better, and you can see if he knocked out some myocardium now that his ticker has been doing overtime. Even if you find some focal wall motion abnormalities, the night after his surgery is not the time to go to the cath lab, but it will put on the right path for managing his hemodynamics. If you're not an echo man, then I think once you've given two or three more liters of fluid, and attempted rate control with esmolol again (maybe start a drip at this point), then its probably time for a PA cath. If your hospital has it you could try the LiDCO. Granted, he's septic, and that's the likely cause, but at this point you've achieved source control, and he should be getting a little better. Plus, new onset a-fib I didn't see a gas from his admit, or start of the case, what were his pH and BD? From resusitation alone you should some get improvement in his hemodynamics, his BP and HR and unchanged since the start of the case. You've done your duty for managing his hypotension, you started with pre-load (he's been well loaded), you moved on to afterload, the only thing left is contractility before you start messing with it too much you need more info on his heart.