CASE PRESENTATION: A 26 year-old Black female JW with SCA presented with sickle pain crisis affecting the torso and extremities. Examination revealed pallor, icterus, tachycardia with clear lungs and abdominal tenderness. Lab data: Hb 7.7gm/dl, WBC 32, platelets 52; Reticulocyte count 2%; HbS 55%; LDH 6077 U/L; haptoglobin 24mg/dl; total bilirubin 2.8 mg/dl. Patient was treated with analgesics, IV fluids, oxygen (O2) therapy and empiric antibiotics. In 48 hours, Hb dropped to 5.2 gm/dl; oxygenation worsened with diffuse lung infiltrates on chest x-ray [CXR] (Figure 1). She was transferred to the ICU for management of ACS. Patient refused transfusion of blood products, with the awareness that death might occur as a consequence. She subsequently required mechanical ventilation for respiratory distress. To minimize O2 consumption (VO2) and energy expenditure, patient was sedated and paralyzed. To increase O2-delivery by increasing O2-solubilty in plasma, 100% FiO2 was used. This was titrated down after 3 days to avoid O2-toxicity. Patient also received erythropoietin, IV iron, folate, thiamine, vitamin B12, vitamin C, antibiotics, IV fluids. Blood draws were limited with Pedi-tubes used when necessary. Table 1 shows Hb trend. Lowest Hb was 3.1gm/dl. Paralytics were discontinued after a week. After 2 weeks, blood counts and CXR began to improve; patient was extubated at 4 weeks. At discharge, a week later, Hb was 7.7g/dl.