CASE PRESENTATION: 50 year-old man with history of alcoholic cirrhosis presented epigastric abdominal pain and seizure. Examination notable 116 beats/minute, 25 breaths/minute and diffuse abdominal tenderness. White blood cell count 12,500 cells/mcL and platelets 73 K/mcL. Lipase 1372 U/L. He was diagnosed with alcohol-associated AP. Clinical course complicated by hemorrhagic pancreatic pseudocyst formation, type 1 respiratory failure requiring intubation and acute tubular necrosis requiring dialysis. On day 46, septic shock refractory to multiple vasopressors ensued. Bedside goal-directed echocardiography revealed massive loculated pericardial effusion with tamponade physiology (Figure 1). In consultation with cardiology, pericardiocentesis was planned however patient expired prior to procedure.