1. intubated and mechanically ventilated at baseline 2. receiving extracorporeal membrane oxygenation (ecmo) at baseline 3. severe organ dysfunction (sofa score \> 10) 4. patient or lar unable to provide written informed consent 5. alt/ast \> 3 times the upper limit of normal or serum bilirubin \> 1.5 times the upper limit of normal 6. estimated glomerular filtration rate (egfr) by modification of diet in renal disease (mdrd) formula \< 30 ml/min/1.73 m\^2 or on dialysis 7. pregnancy or breast feeding. 8. anticipated transfer to another hospital which is not a study site within 72 hours. 9. allergy to any study medication

1. intubated and mechanically ventilated at baseline 2. receiving extracorporeal membrane oxygenation (ecmo) at baseline 3. severe organ dysfunction (sofa score \> 10) 4. patient or lar unable to provide written informed consent 5. alt/ast \> 3 times the upper limit of normal or serum bilirubin \> 1.5 times the upper limit of normal 6. estimated glomerular filtration rate (egfr) by modification of diet in renal disease (mdrd) formula \< 30 ml/min/1.73 m\^2 or on dialysis 7. pregnancy or breast feeding. 8. anticipated transfer to another hospital which is not a study site within 72 hours. 9. allergy to any study medication

intubated and mechanically ventilated at baseline receiving extracorporeal membrane oxygenation (ecmo) at baseline severe organ dysfunction (sofa score > 10) patient or lar unable to provide written informed consent alt/ast > 3 times the upper limit of normal or serum bilirubin > 1.5 times the upper limit of normal estimated glomerular filtration rate (egfr) by modification of diet in renal disease (mdrd) formula < 30 ml/min/1.73 m^2 or on dialysis pregnancy or breast feeding. anticipated transfer to another hospital which is not a study site within 72 hours. allergy to any study medication

intubated and mechanically ventilated at baseline receiving extracorporeal membrane oxygenation (ecmo) at baseline severe organ dysfunction (sofa score > 10) patient or lar unable to provide written informed consent alt/ast > 3 times the upper limit of normal or serum bilirubin > 1.5 times the upper limit of normal estimated glomerular filtration rate (egfr) by modification of diet in renal disease (mdrd) formula < 30 ml/min/1.73 m^2 or on dialysis pregnancy or breast feeding. anticipated transfer to another hospital which is not a study site within 72 hours. allergy to any study medication

1. intubated and mechanically ventilated at baseline 2. receiving extracorporeal membrane oxygenation (ecmo) at baseline 3. severe organ dysfunction (sofa score > 10) 4. patient or lar unable to provide written informed consent 5. alt/ast > 3 times the upper limit of normal or serum bilirubin > 1.5 times the upper limit of normal 6. estimated glomerular filtration rate (egfr) by modification of diet in renal disease (mdrd) formula < 30 ml/min/1.73 m^2 or on dialysis 7. pregnancy or breast feeding. 8. anticipated transfer to another hospital which is not a study site within 72 hours. 9. allergy to any study medication

1. intubated and mechanically ventilated at baseline 2. receiving extracorporeal membrane oxygenation (ecmo) at baseline 3. severe organ dysfunction (sofa score > 10) 4. patient or lar unable to provide written informed consent 5. alt/ast > 3 times the upper limit of normal or serum bilirubin > 1.5 times the upper limit of normal 6. estimated glomerular filtration rate (egfr) by modification of diet in renal disease (mdrd) formula < 30 ml/min/1.73 m^2 or on dialysis 7. pregnancy or breast feeding. 8. anticipated transfer to another hospital which is not a study site within 72 hours. 9. allergy to any study medication