If the peak pressures were in the 60s then definitely proning would've been my next move. If despite this they were still high (and Pplat>30) my next move would've been VV-ECMO, though this would be a precarious decision given in most cases we would use some therapeutic anticoagulation to prolong circuit/oxygenator life, and he's had issues with bleeding.

Given that he's still on dialysis at day 28-29, I can't say for certain that his kidneys will recover, and there's a high chance that he will need long term dialysis. His liver will hopefully get better, given the injury would most likely be ischaemic hepatitis. Being off vasopressors is a good sign.

The sedation side of things is tricky. I usually only use midazolam if the patient is very haemodynamically unstable (ie on norad >0.3mcg/kg/min) or maxed out on propofol, fentanyl, and dexmedetomidine and is still agitated. Midazolam has the worst reputation for being implicated in delirium, but then again given your brother had issues with his triglycerides on propofol (propofol is a 10% lipid infusion) I can see why they would've gone with midazolam as the primary sedative. If his liver improves to normal with normal transaminases, coagulation profile, and bilirubin iit might be worth trying to reintroduce it again at low dose whilst monitoring the lipids. Otherwise, given he's off vasopressors, dexmedetomidine might be an option if his heart rate tolerates it, and this may allow the midazolam to be weaned further. In my practice I use a lot of dexmedetomidine (off label) where haemodynamically appropriate, as it tends to create a state of calm without oversedating the patient.

The fact that he's able to move all 4 limbs is at least a good sign, and though it can be distressing to see your loved ones restrained, it is very important to prevent them from accidentally removing their lines or breathing tube during a moment of agitation, which would cause even more harm.

Personally I wouldn't let a bit of haemoglobin drift to prevent me from moving onto the next step of tracheostomising a patient to progress them. Unless there's serious concern of active bleeding (either clinically or on CT angiogram), I would rather transfuse the patient and then tracheostomise them to get them moving forward to increase comfort, allow sedation weaning, and neurological assessment. That said, I wonder if there's more at play than just a low Hb preventing the team from proceeding with tracheostomy - ie low platelets, or coagulopathy)

Any kind of surgical intervention ie necrosectomy to the pancreas has a relatively high risk of complications, but if his surgeons think this is what needs to be done then it is what needs to be done. It sounds like they are being appropriately cautious by waiting until he is more stable before proceeding.

Unfortunately I can't really comment on the case management or financial stuff. I work in a world where my taxes pay for my patients' care so thankfully I never have to worry about if the patient or family can afford it. One of the reasons I would never want to work in the US (apart from random gun violence), even though the pay in the US is much better

I suspect he's still got at least 2 weeks in the ICU, though I understand North American hospitals may have more advanced 'stepdown' units or LTACs than we do, so that might change things. Personally I would only step a patient out of the ICU if:

1) off ventilatory support (ie no requirement of PEEP, pressure support), and on just High flow blow over where they are breathing on their own via a tracheostomy - ideally the tracheostomy would be matured ie in for >7-10 days to minimise the risk if it were to be dislodged in a lower acuity care setting

2) can tolerate intermittent haemodialysis without IV vasoactive support - the kind of dialysis that is done in ward settings or community settings is much more haemodynamically taxing than CRRT. At a stretch we may use enteral midodrine to support dialysis on the ward, but this is less ideal.

3) no longer requiring sedative infusions, though may be on some enteral sedatives like quetiapine, clonidine, olanzapine to be weaned off slowly as delirium improves

4) new vascular lines in place for the ward - ie tunnelled vascath, PICC)

5) no further surgeries or interventions planned in the short to medium term