A previously healthy 86-year-old Sundanese man with no comorbidities was admitted to the general ward of our hospital with excruciating pain in his right hip and knee after a prior fall. Our patient weighed 65 kg and was 165 cm tall. On admission, he was fully alert, and the results of his radiologic investigations were normal. Intravenous analgesics and nerve blocks were administered, and the patient remained hospitalized for 12 days of nursing care. On the 12th day, intravenous catheter site induration and redness developed, which rapidly progressed to necrotic and pustular tissue formation within 12 h. A wound culture was taken, and intravenous antibiotic therapy was promptly initiated; nevertheless, the patient’s condition worsened on day 14 of his hospitalization, and he became lethargic. Our patient was moved to the high-care unit (HCU) with the following hemodynamic parameters: blood pressure 107/46 mmHg, mean arterial pressure (MAP) 66 mmHg, heart rate 88 beats per minute (bpm), respiratory rate 21 breaths per minute, and oxygen saturation 100% through a 5-L nasal cannula. He remained afebrile. A complete blood examination revealed hemoglobin (Hgb) 1.94 g/dl (reference range 11.70–15.50 g/dl), hematocrit (Hct) 32.35% (reference range 35.00–47.00%), white blood cell count (WBC) 20,550/mm3 (reference range 3600–11,000/mm3), platelets (Plt) 137,700/μl (reference range 150,000–440,000/μl), C-reactive protein 199.90 mg/L (reference range 0.00–3.00 mg/L), and procalcitonin (PCT) 37.00 ng/ml (reference range <0.5 ng/ml). Other levels recorded were alanine aminotransferase 13 U/L (reference range 0–55 U/L), aspartate transaminase 12 U/L (reference range 5–34 U/L), urea 126.0 mg/dl (reference range <50 mg/dl), creatinine 2.42 mg/dl (reference range 0.5–1.1 mg/dl), Na+ 131 mEq/L (reference range 135–145 mEq/L), K+ 6.2 mEq/L (reference range 3.5–5 mEq/L), Cl− 101 mEq/L (reference range 96–110 mEq/L), and random blood glucose 114 mg/dl. A diagnosis of necrotizing fasciitis with sepsis, stage 2 acute kidney injury, and hyperkalemia was made. One gram of intravenous cefoperazone twice daily and 400 mg of moxifloxacin once daily were given. The patient’s hyperkalemia was treated using 25 U of insulin and 100 ml of 40% dextrose solution for 2 h. A nasogastric tube was inserted, and the patient’s stomach was decompressed. A central venous catheter was inserted, and cultures from blood, urine, and sputum were taken. Nevertheless, the patient’s condition worsened. He became unresponsive with a respiratory rate of 38 breaths per minute and prominent use of accessory muscles. His oxygen saturation was 88% with a 15-L non-rebreathing mask; his central venous pressure (CVP) was 5 mmHg; his blood pressure was 90/60 mmHg (MAP 70 mmHg); and he had an electrocardiographic reading of atrial fibrillation with rapid ventricular response and a heart rate of 140–160 bpm. Arterial blood gas analysis revealed respiratory acidosis with pH 7.029, partial pressure of carbon dioxide (pCO2) 77.9 mmHg, partial pressure of oxygen (pO2) 94 mmHg, HCO3 − 20.9 mEq/L, base excess −10 mEq/L, and serum lactate 3.3 mmol/L (reference range <0.6–2.2 mmol/L). The patient’s blood pressure continued to fall and reached 60/30 mmHg (MAP 40 mmHg), followed by multiple episodes of bradycardia from 140 bpm to 70 bpm despite administration of 500 ml of colloid and 100 ml of 20% albumin. Hence, noradrenaline at 0.5 μg/kg/minute and dobutamine at 10 μg/kg/minute were initiated. In the HCU, the patient received a total fluid input of 4644 ml with urine output of 55 ml/h and fluid balance of +3540 ml/20 h. The patient was promptly transferred to the intensive care unit (ICU), where he was intubated and mechanically ventilated. He was placed on adaptive support ventilation mode with a positive end-expiratory pressure of 5 cmH2O and a fraction of inspired oxygen of 0.5. At this time, his blood pressure plummeted to 80/50 mmHg (MAP 60 mmHg), and his CVP was 16 mmHg. Noradrenaline was increased to 0.8 μg/kg/minute and dobutamine to 3 μg/kg/minute, to which he responded. His blood pressure was maintained at 115/60 mmHg (MAP 78 mmHg); his heart rate was 110–120 bpm; and his CVP was 12 mmHg. Two hours postintubation, his blood gas analysis revealed pH 7.28, pCO2 39.6 mmHg, pO2 112.5 mmHg, HCO3 − 19.1 mEq/L, base excess −6.9 mEq/L, and a lactate level decreasing to 2.27 mmol/L. A chest x-ray revealed patchy infiltrates on the lower lung regions with a cardiothoracic ratio of 61%, and echocardiography revealed an ejection fraction of 67% with no ventricular wall motion abnormalities. Continuous analgesia and sedation with morphine and midazolam infusion were administered, and the patient’s vital signs stabilized. A repeat blood workup revealed insignificant changes except for urea and creatinine increasing to 159.5 mg/dl and 2.74 mg/dl, respectively. The patient’s PCT levels spiked to 97.60 ng/ml, and antibiotics were switched to meropenem 1 g every 8 h, moxifloxacin 400 mg once daily, and 200 mg fluconazole twice daily. At that time, our patient received 1000 kcal/500 ml of parenteral nutrition through intermittent bolus nasogastric feeding tubes. On the second day, the results of a wound culture revealed the growth of Streptococcus pyogenes, and meropenem was changed to 400 mg of teicoplanin daily along with moxifloxacin, based upon antibiotic sensitivity results. Cultures from the patient’s blood and urine revealed no growth, whereas a sputum culture revealed growth of Candida albicans, and a fluconazole regimen was resumed. The patient’s blood gas analysis normalized with pH 7.38, pCO2 40.6 mmHg, pO2 138.8 mmHg, HCO3 − 16.6 mEq/L, base excess −3.9 mEq/L, and serum lactate 1.3 mmol/L. His blood pressure was stable at 110/50 mmHg (MAP 70 mmHg); his heart rate was 100–120 bpm with atrial fibrillation; and his CVP was 12 mmHg. Intravenous amiodarone at 150 mg for 10 minutes was given, followed by a continuous infusion of 150 mg for 12 h. Wound debridement and necrotomy were performed on the second day. However, 1 h postdebridement, the patient’s blood pressure plummeted to 50/30 mmHg (MAP 38) with a heart rate of 100 bpm. A bolus of 100 ml of normal saline was given along with noradrenaline at 0.8 μg/kg/minute and epinephrine at 8 μg/kg/minute. The amiodarone infusion was stopped. The patient’s vital signs responded progressively, and epinephrine was slowly tapered and then completely discontinued after 2 h. Maintenance fluids were given at 40 ml/h normal saline with a total daily fluid input of 3850 ml, diuresis of 70 ml/h, and a daily fluid balance of +1255 ml. On the third day, the patient’s mental status improved dramatically; he was able to respond to instructions, and his vital signs remained within normal limits. The ventilator mode and settings remained unchanged, and the patient was actively triggering breaths with good ventilator synchrony. A complete blood examination revealed Hgb 9.9 g/dl (reference range 11.70–15.50 g/dl), Hct 24.5% (reference range 35.00–47.00%), WBC 24,190/mm3 (reference range 3600–11,000/mm3), and a PCT level decreasing to 83.46 ng/ml. His coagulation profile revealed Plt 149,000/μl (reference range 150,000–440,000/μl) with a prothrombin time (PT) of 13.60 seconds, international normalized ratio (INR) of 1.15, activated partial thromboplastin time (aPTT) of 55.40 seconds, and D-dimer of 5.36 ng/ml. His urea decreased slightly to 151.7 mg/dl (reference range <50 mg/dl); his creatinine was 1.84 mg/dl; and his serum albumin was 2.88 mg/dl (reference range 3.5–5.3 mg/dl). Enteral nutrition was resumed because no residual gastric fluid was noted, and the maintenance fluid used was normal saline at 20 ml/h with noradrenaline tapered to 0.01 μg/kg/minute. Total daily fluid input was 2198 ml with diuresis of 91 ml/h and a fluid balance of −967 ml. On the fourth day, the vasopressor infusion was discontinued. The patient remained afebrile and responsive; hence, weaning from mechanical ventilation was initiated. His vital signs remained stable throughout the weaning process, with a blood pressure of 110/70 mmHg (MAP 83 mmHg), heart rate of 85–90 bpm, and CVP of 9 mmHg. His physical examination revealed clear lung sounds confirmed by a clear chest x-ray, and the results of his arterial blood gas analysis were within normal limits. The maintenance fluid used was normal saline at 40 ml/h with a total daily fluid input of 2610 ml, diuresis of 100 ml/h, and a fluid balance of −765 ml. On the fifth day, the patient was extubated. His vital signs remained stable 1 h postextubation with a respiratory rate of 18 breaths per minute and CVP of 10 mmHg, and his arterial blood gas analysis showed pH 7.428, pCO2 26.4 mmHg, pO2 173.1 mmHg, HCO3 − −17.8 mEq/L, and base excess −5.1 mEq/L. A repeat blood workup revealed Hgb 10.28 g/dl, Hct 31%, WBC 17,380/mm3, and Plt 114,000/μl. Other readings were PT 14.60 seconds, INR 1.24, aPTT 43.80 seconds, and D-dimer 5.90. The patient’s urea level was 130.9 mg/dl, and his creatinine level was 1.24 mg/dl. His nasogastric tube was withdrawn, and he was started on oral feeding. Normal saline was given at 20 ml/h with a total daily fluid input of 2562 ml, diuresis of 148 ml/h, and a daily fluid balance of −1998 ml. On the sixth day, he was discharged to the general ward. Normal saline was given at 20 ml/h with a total daily fluid input of 1858 ml, diuresis of 143 ml/h, and a daily fluid balance of −2537 ml. An order to complete his 10-day course of intravenous moxifloxacin and his 14-day course of intravenous teicoplanin was completed, and he was discharged to home after 10 days of care in the general ward, without any negative sequelae. Throughout his stay, our patient received metoclopramide, proton pump inhibitors, and daily nebulized salbutamol and mucolytic agents. Endotracheal suctioning was carried out as needed through a closed system device. Additionally, deep vein thrombosis prophylaxis was carried out using compression stockings and an intermittent pneumatic device. The wound site was cared for meticulously with daily dressing changes, and healing progressed significantly. Daily fluid balance was calculated by accounting for fluid input as all fluids administered through intravenous or nasogastric routes and metabolism products, which were one-third the value of insensible water loss (325 ml/day). Fluid output was counted as fluids collected from urine, wound drainage, nasogastric fluids, and insensible water loss, which was calculated at 15% of body weight in milliliters (975 ml/day).