Acute Pancreatitis

Patient Case Presentation

Presented by: Angelie Ruiz, Karla Yuret & William Torres, Pharm D. Candidates 2022
Nova Southeastern University, College of Pharmacy
Block 6 : Internal Medicine at the Intensive Care Unit
Preceptor: Yarelis Alvarado, Pharm D.
 Table of Contents

01 02 03
About the Diagnostics Discuss hospital
Patient course

04 05
Treatment Provide critique
Guidelines about treatment
plan
 Objectives
Explain pathophysiology of pancreatitis, acute kidney injury and
Explain acute respiratory distress syndrome.

Evaluate Evaluate acute medical treatment in the intensive care unit.

Assess Assess patient case and identified drug-related problems.

Develop Develop an appropriate treatment critique for the patient.

01
About the Patient
Patient Medical History
o Name: JSB
o DOB: 1/05/1994 (27 y/o)
o Date of admission: 11/02/2021
o Admission weight: 230 lbs (104.3 kg)
o Height: 5’8” (68 in)
o Ethnicity: Hispanic
o Gender: Male
o Allergies: None
 Patient Medical History

Chief Complaint History of Present Illness

o Patient presents to the ER o 27 y/o Hispanic male patient
with abdominal pain, experiencing acute abdominal pain
shortness of breath, on a scale of 10/10 for the last 2
nausea and vomiting. days ago.

o Pain is sharp and pulsating in

nature with radiation towards the
back.
 Patient Medical History

Review of Systems Family/Social History

o Significant abdominal pain o No alcohol, tobacco, or
reported by patient as 10/10 of illicit drug use.
intensity. Presents abdominal
distention, sweaty, nausea and
vomiting with no blood. Past Medical History
o Mayor depression, anxiety,
o Patient denies heart
insomnia and PTSD.
palpitations, fever and diarrhea.
 Patient Medical History

Medications Prior to Admission:

○ Venlafaxine 75 mg PO daily

○ Quetiapine 200mg PO daily

○ Clonazepam 0.5mg PO daily

Immunizations:
○ Up to date according to patient

○ Covid-19 vaccine Johnson & Johnson in

May 2021
 Physical Examination

GI Skin MSK Neuro Heart Lungs

Abdominal pain 10/10 Dry pale and sweaty Normal ROM, motor Neurologic Tachycardia, normal CTA x2
scale, sharp and strength 5/5 in all weakness (GCS:15) S1 and S2
pulsating, +BS extremities
 Admission Assessment
Vital Signs
BP (MAP) RR SpO2 HR
140/85 (103) 21 99 130

Special Labs CBC BMP

Amylase 1,160 Hgb 20 Glu 91 K 4.6

Lipase 774 Hct 54.7% BUN 14 Cl 91
WBC 14.46 Scr 0.75 CO2 21
(10x3uL)
Plt (10x3uL) 163 Na 131 Ca 7.3
Mg 2.45
 02
Diagnostics
Prioritized Problem List

Acute Pancreatitis

Acute Kidney Injury

ARDS
 Pancreatitis (DiPiro)

• Gastrointestinal inflammatory condition of

the pancreas causing a systemic inflammatory
response syndrome (SIRS) and organ failure
• Characterized by severe pain and elevations
of pancreatic enzymes
• Approximately 20% of adults develop a
severe course
• Severe pancreatitis comprise 30% of
mortality, while mild is less than 1%
 Pancreatitis (DiPiro)

Epidemiology
• Is the 3rd most common GI disorder
• Leading cause of inpatient care with an incidence of 3 to 30 cases per
100,000 and rising
• > 275,000 patients hospitalized annually
• Overall fatality = 5% *increases with severity
• African Americans have 2 to 3 times higher risks than Caucasicans
• Increased hospitalization cost of >$2.6 billion per year
 Pancreatitis (DiPiro)
Pathophysiology:

Initial insult = zymogen activation, ischemia & duct obstruction

Release of vasoactive substances, active enzymes & cytokines

Vascular damage , ischemia, inflammation, tissue damage & cell

death
 Acute Pancreatitis (AP) (AGA, WSES)

Etiology
Diagnostic Laboratory Parameters
Common symptoms:
• Abdominal pain 1. Serum amylase and lipase
• Nausea 2. C-reactive Protein level ≥ 150 mg/l = severe AP
• Vomiting 3. Hematocrit > 44% = independent risk factor of
necrosis
Common causes: 4. Urea > 20 mg/dl = independent predictor of
• Gallstones and alcohol (80%) mortality
• Medications 5. Procalcitonin = most sensitive; predictor of
• Pancreatic solid and cystic malignancies infected necrosis
• Hypertriglyceridemia
 Acute Pancreatitis (AGA)

Diagnosis requires 2 or more

characteristics:

Abdominal
pain
Elevation of
amylase or
lipase >3
xULN
Cross-
sectional
radiography
 Acute Pancreatitis (AGA)

Mild Only intestinal changes

Transient local or systemic

Moderate complications, or transient
organ failure (<48 hours)

Severe Persistent organ failure

*Necrotizing pancreatitis can be seen in moderate or severe pancreatitis

Acute Pancreatitis (WSES Guideline)
Treatment (DiPiro)
 Acute Kidney Injury (AKI)
• Abrupt reduction in kidney function*
o Elevation of serum creatinine
o Reduction of urine output
o May need renal replacement therapy (RRT)
• Associated with high morbidity and mortality
• Can lead to chronic kidney disease or end stage
renal disease
• AKI occurs in 30% to 60% patients in intensive
care unit (ICU)#
• Renal replacement therapy is used approx. in 5%
to 11% of critically ill patients with AKI
• 50% mortality for ICU patients

*KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012;
2: 1-138.
 Acute Kidney Injury (AKI)
Serum creatine level Urine output
Increase of ≥0.3mg/dL
within 48 hours
Diagnosis* OR <0.5ml/kg/h for 6 hours
Increase of ≥1.5-fold above
baseline within 7 days

Prevention*
• Volume status optimization (IV fluids)
• Hemodynamic support
• Assessment of risks vs benefits of potentially nephrotoxic medications

*KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1-138.
 Acute Kidney Injury (AKI)
Staging of AKI*
Stage Serum creatine level Urine output
1.5-1.9 times baseline
1 OR <0.5 ml/kg/h for 6-12 hours
≥0.3mg/dL increase
2 2.0-2.9 times baseline <0.5 ml/kg/h for ≥12 hours
3.0 times baseline
OR
<0.3 ml/kg/h for ≥24 hours
Increase in serum creatinine
3 to ≥4.0 mg/dL
OR
Anuria for ≥12 hours
OR
Initiation of RRT

*KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1-138.
 Acute Kidney Injury (AKI)

Pre-renal Risk Factors

Critical illness

Volume depletion
AKI Intrinsic Radiocontrast agents

Nephrotoxic drugs

Chronic diseases
Post-renal

*KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1-138.
 Treatment of Acute Kidney Injury
Treatment*
• Main goal is to restore renal function to pre-AKI baseline
• No specific treatment that can reverse AKI
• Supportive measures
o Hemodynamic support (maintenance of renal perfusion)
 Fluids and/or vasopressors
o Fluid balance
 Crystalloids
o Acid-base balance
o Electrolyte homeostasis
 Potassium
 Sodium
• Initiate RRT when life-threatening changes in fluid, electrolyte, and acid-base
balance exist (Intermittent hemodialysis, continuous renal replacement)

*KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1-138.
Acute Respiratory
Distress Syndrome
 Acute respiratory distress syndrome

Is a serious lung injury The injury cause a The lung damage causes
that causes respiratory release of cytokines, an excess of fluid in the
failure. damaging the alveolar alveoli which in turn can
epithelium. lead to impaired gas
exchange.
 ARDS Epidemiology

• Approximately 10-15% of the patients in the • The incidence of ARDS tends to be

Intensive Care Unit (ICU) meets the criteria higher in the United States and Europe.
for ARDS.

• 35-45% of mortality rate

 Acute respiratory distress syndrome
Signs and Symptoms: Causes:

Sepsis

Shortness of breath Tachypnea Pneumonia

Severe trauma

Blood transfusions
Hypoxemia Anxiety
Inhalation of harmful substances

Pancreatitis
 Acute respiratory distress syndrome
Diagnosis:
• Bilateral opacities present on CT scan
• Respiratory failure
• Oxygen Impairment
o PaO2/FiO2

Treatment Management
• Oxygen
• Fluid Management
• Mechanical Ventilation
o Sedative-analgesic medications
o Neuromuscular blockers
Hospital
Course
● Admission date: 11/02/2021
● Deceased: 11/23/2021
● Length of Stay: 21 days
 Case Timeline

Phase 1 Phase 2 Phase 3 Phase 4

High triglycerides and Persistent arrhythmias,; PE Patient develops AKI Scr Patient starts
pancreatitis upon admission is suspected. Ct with goes from 1.79 to 3.09 to descompensating and
complicated by ARDS and contrast is ordered and 5.31 Oxygen saturation starts to
patient is intubated enoxaparin full treatment decrease (82%)
dose is started.
Laboratory
Values,
Medications
and
Diagnostic
Imaging
 Hospital Medications
Indication Medication Start Stop

DVT prophylaxis Enoxaparin 40mg SQ daily 11/6 11/10 (full dose)

Bacterial prophylaxis Meropenem 1 g IV q 12hrs 11/6 11/15
PUD prophylaxis Famotidine 11/6 11/23
Sedation/agitation Lorazepam 1 mg IV STAT 11/7 11/7
Sedation/agitation Lorazepam 2 mg IV STAT 11/7 11/7
Fluids KCl 20mEq/100mL (línea jugular) 11/7

fluids K3PO4 21mmol/250mL 11/6

Agitation Haloperidol 5mg IM q8hrs 11/8 11/8
Pain Fentanyl 1,250 mg (10ml/hr) 11/10 11/23
High blood pressure Enalaprilat 1.25mg IV q6hrs (PRN) 11/6 11/6
Nausea Ondansetron 4mg IV q6hrs (PRN) 11/6 11/6
 Hospital Medications
Indication Medication Start Stop

sedation Midazolam 100 mg IV CI 10mL/hr 11/8 11/23

sedation Propofol drip 10mL/hr 11/8 11/9
High blood pressure Metoprolol tartrate 5mg IV (HR>120) 11/8
Fever Acetaminophen 650mg SUP q 6hrs (PRN) 11/8
Heart rate Diltiazem 125 mg/100 mL NSS CI 5mL/hr; 10ml/hr; 15ml/hr 11/8
Heart rate Diltiazem bolus 200 mg IV x 1 11/8
Heart rate Amiodarone 900 mg/500 mL D5W at 33mL/hr for 7hrs then 16mL/hr for 15hrs 11/10

Bacterial prophylaxis Vancomycin 1,500mg IV q12hrs IV 11/8

Bacterial prophylaxis Vancomycin 1,500mg IV daily 11/13
Bacterial prophylaxis Vancomycin 750mg daily (post HD) 11/14 11/23
Bacterial prophylaxis Vancomycin 1,750 q12h 11/11
Neuromuscular blocker Cisatracurium 200mg IV CI 11/8 11/13
Bacterial prophylaxis Imipenem/cilastatin 500 mg IV q6hrs 11/9?? 11/14
 Lab values
Date 11/22 11/21 11/20 11/19 11/18 11/17 11/16 11/15 11/14 11/13 11/4 11/3 11/2

Scr 6.37 6.74 5.23 5.22 5.06 5.21 5.31 3.84 3.90 3.09 2.16 1.24 0.75

Na 139 138 138 141 140 142 143 144 152 154 137 136 131

Glu 241 415 146 145 155 247 205 196 215 252 123 128 91

Cl 101 103 102 105 104 108 109 110 115 113 105 98 91

K+ 6.3 7.6 5.5 5 4.6 4.5 5.8 4.3 4.3 5 4.0 4.2 4.6

Ca+ 7.9 8.1 8.2 8.2 8.5 8.3 7.8 7.7 8.0 7.7 4.2 5.0 7.3

CO2 22 19 22 22 22 23 23 26 27 25 23 24 21

HCO3 29 23.2 26.4 26.4 27.2 28.7 34.1 32.2 32.4

Alb 1.6 1.4 1.3 1.3 1.4 1.4 1.2 1.2 1.3 1.4 1.9 2.3

Pho 8.3 8.8 6.3 3.8 4 4.1 3.4 2.4 1.6 2.9

Anion 16 16 14 14.0 11 11 8 10 16 19
gap
 Lab values

Date 11/22 11/20 11/19 11/17 11/16 11/15 11/14 11/13 11/12 11/11 11/10 11/9 11/2

WBC(10^3/uL) 18.3 18.21 16.53 17.21 17.57 15.54 12.54 18.46 23.85 20.78 24.64 32.22 23.88

Hgb(10^6/uL) 8 7.6 8.0 8.8 7.9 8.3 7.6 8.1 9.3 7.3 8.3 10.8 20.6

Htc (%) 26.2 25 26.1 28.4 26.4 27.4 25.5 27.2 31.0 24.8 28 34.9 56.7

PLT (10^3/uL) 223 238 251 318 286 244 222 277 234 229 298 366 214

Neu% 90 87 85 73 70 64 81 91 91 86 20.0 87 90

Mono% 3 4 4.0 5 8 3 4 3 1 3 1.0 2 1

Bands% 1 7 4 8 13 5 - 5 4 4 2 9
Urine output

Date IV FLUID intake Total Output

11/09 4237 1600
11/17 2784 210
11/18 2107 780
11/19 2044 1700
11/20 2282 460
11/21 3678 400
 Special laboratory test

Date Vancomycin Dose Vancomycin through Arterial Blood Gases Values

11/10 1500mg IV q12h 9.9
Date PEEP PaO2/FiO2 SpO2 %
11/12 1750mg IV q12h 17.90
11/9 10 68.7 95

11/11 10 137 95
Date Procalcitonin
11/15 16 56.7 90
11/08 0.85
11/22 14 74.4 81
11/18 9.56
 Special laboratory test

Date 11/15 11/14 11/13 11/05/21 11/04/21 11/02/21

Amylase 323 231 246 177 310 1,160

Lipase 163 116 107 76 118 774

Date 11/22 11/12 11/08 11/04/21

Triglycerides
(mg/dL) 148 197 81 1577
Imaging
Chest x-ray impression
• Lower lungs opacities
• Pleural effusion
• Opacities at the bilateral lower lungs and
the left upper lung

Abdomen and Pelvis impression

• Thickening and enlargement of the
pancreas compatible with acute
pancreatitis
• Small amount of abdominal and pelvic
ascites
• No bowel obstruction
• Normal appendix
 Hospital Course

Phase 1 Phase 2 Phase 3 Phase 4

High triglycerides and Persistent arrhythmias, PE Enoxaparin full treatment Patient starts
pancreatitis upon admission is suspected. Patient dose for suspected PE. decompensating and
complicated by ARDS and develops AKI; Scr goes NMB started Oxygen saturation starts to
patient is intubated from 1.79 to 3.09 to 5.31 decrease (82%)
Hospital Course: Day 1 to 7 phase1
● Day 1: Admission date 11/02/2021 7:32am. CT abdomen/pelvis w/o contrast. Final
diagnosis of acute pancreatitis
● Day 2: Metabolic acidosis, abdominal pain 6/10, 7mm stones in seen in the midpole of the
right kidney. Irregular rate and rhythm with normal S1 and S2.
o BISAP 2
o SOFA 4 points = 33% mortality
● Day 3: Blood culture (-); Sputum culture (-); HR 128; NPO
● Day 4: Partial distention of the stomach, ileus found on KUB. Placement of central line
and NGT
● Day 5: Abdomen/pelvis CT scan with IV contrast performed
● Day 6 (11/7): Patient diagnosed with AKI; Endotracheal intubation (2:40pm) (SpO2:
82%). GCS 10/15
● Day 7: Patient started on Nimbex 20mL/hr.
● Irregluar HR cardiovertion HR decrease 140; SpO2, on MV 94-95
● CT  abdomen/pelvis w/ contrast + CT chest angiography with contrast (Scr=0.90)
Hospital Course: Day phase2
● Day 8 (11/9): Full dose enoxaparin for suspected PE. Sedation: Fentanyl 10ml/hr
● Day 9 (11/10): Start amiodarone 100mg IV q12hrs. Sedation: Versed 10ml/hr Analgesia:
Fentanyl 10ml/hr
● Severe pancreatitis gastro ranjon criteria
● Day 10(11/11): First blood transfusion; Started Furosemide. Levophed 8mg/250 for map>
60 
● Day 11(11/12): (+) coagulase negative staphylococcus; start Humulin R 10 U and D5W
25mg IV for hyperkalemia (K+=)
● Day 12 (11/13): Rocuronium 100/100 @26ml/hr; retacrit 10,000 units BID. NPO.
● Day 13 (11/14): Pt started on dialysis. Discontinue Lasix & primaxin; start meropenem
500mg IV QD & Vancomycin dose decreased 750mg IV daily after dialysis. DVT
prophylaxis switch to Heparin 5000 SQ daily. SaO2 87%. Hgb=7.9
● Day 14 Blood transfusion, Pt started on levophed and Cardizem drip. MRSA
(+). Fluids and medications concentrated due to edema: Change rocuronium 500
mg in 50 ml NSS; total volume 100ml 5ml/hr ; Levophed 16mg/250ml
@12.5 ml/hr. Merrem increased 1gm daily. Saturations decreasing Sat 85%
(AM). Multiorgan failure and no improvement after receiving maximal medical
therapy. Sat 98% (PM). Intravesical pressure= 18
● Day 15: Blood transfusion. Scrotal edema, leg edema Grade II, bowel sounds
decreased. Possible focal necrosis on tail of pancreas.
● Day 16: No new events. ** blood transfusion **.
● Day 17 (11/18): Intravesical pressure every 8 hrs.
● Day 18: No new events
● Day 19: blood transfusion, Hold Heparin 5000 SQ daily. Severe pancreatitis
necrosis
● Day 20: blood transfusion.
● Day 21: Worsening hypoxemia. SpO2: 82%
 03
Discussion
Discussions Summary

Causa de pancreatitis en JS
01
Manejo de medicamentos
02
Complicaciones
03
 Guideline Recommendation: Pancreatitis
● For infected necrosis antibiotic prophylaxis is recommended for severe AP (2A)
● Procalcitonin levels may be valuable predicting the risk for infected pancreatic necrosis (1B)
● CT-guided fine-needle aspiration for gram stain and culture can better confirm infection and drive
the therapy (1B
● Continuous vital signs monitor is recommended in all patients
● Early fluid replacement with isotonic crystalloids are preferred
● Fluid volume should be adjusted based on age, weight, renal or heart conditions
o Volemia monitoring & adequate tissue perfusion to be monitored with labs
● Pain control is highly recommended
● Mechanical Ventilation if ineffective oxygen supply is recommended
● Enteral nutrition over parenteral is recommended

Leppäniemi et al. World Journal of Emergency Surgery (2019) 14:27

https://doi.org/10.1186/s13017-019-0247-0
 Pancreatitis Evaluation Therapy

Assessment Critique

• Infected necrosis: • Vancomycin starting dose was too low

• Vancomycin 1,500mg IV q 12h started on 11/08 • Recommended dose should be 1,750 q 12h to achieve
(Through = 9.9) an AUC/MIC of 489 and through of 12
• Procalcitonin levels drawn • Dialudid is recommended over morphine or fentanyl for pain
• Fluid replacement: control.
• normal saline started upon admission 11/02 • Enteral nutrition is recommended to start within the first 24
• fluid volume adjusted upon patient presented edema on hours of hospital admission to maintain gut barrier function
11/15 and prevent early bacterial translocation
• Enteral nutrition:
• NGT placed on 11/05 and patient remained NPO the
whole course
 Guideline Recommendation: AKI

● For patients with AKI, current guidelines recommend isotonic crystalloids as initial management for
expansion of extravascular volume (30ml/kg NSS or Lactated Ringer)
● Vasopressor are recommended along with fluid if hypotension does not resolve
● Avoid nephrotoxic drugs/agents:
o Amphotericin B
o Cisplatin
o IV contrast
o Aminoglycosides
• Renal replacement therapy in patients with fluids, electrolytes and/or acid/base imbalance
o Intermittent hemodialysis
o Continuous renal replacement

*KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1-138.
 AKI Evaluation Therapy

Assessment Critique

 AKI  AKI
 Guideline Recommendation: ARDS

● ARDS

ARDS Guideline
Neuromuscular blocking agents (NMBAs)

Guidelines recommend the use of PaO2/FiO2 ratio of <150 mmHg 

NMBAs in severe ARDS.

These agents have the potential to reduce ventilator asynchrony and

optimize mechanical ventilation.

They are not used as a first line treatment the patient must be under
analgesia and deep sedation before administration.

Rocuronium
The most common NMBAs are:
Cisatracurium
 • Before administering an NMBA the patient
should receive analgesia and sedative
medication.
• The goal of analgesia/sedation
management is to provide comfort and
safety.
Analgesia and • Opioids are recommended for pain relief, at
Sedation the lowest effective dose in critically ill
patients.
• Commonly use opioids in critically ill
patients are:
• Fentanyl
• Morphine
• Hydromorphone
 Analgesia and Sedation
• The use of sedatives is indicated for anxious and agitated patients when
pain has already been treated.
• The Richmond Agitation Sedation Sedation Scale (RASS) is used to assess
the level of sedation needed.
• Guidelines recommend for sedation

Propofol Dexmedetomidine Benzodiazepines

• Deep sedation • Not for deep sedation • Midazolam

• Hypertriglyceridemia • Lorazepam
• propylene glycol-related
acidosis
• Are associated with
increased time in
mechanical ventilation and
higher incidence of delirium.
 ARDS treatment management

It is recommended that patients Analgesic and sedative

receive DVT prophylaxis therapy. therapy should be continue
• Enoxaparin as long as NMBA are
• Heparin administered.

Stress ulcer prophylaxis is also The choice of agent should

recommended. be determined according to
• Famotidine the patient’s specific factors.
• Pantoprazole

NMBA discontinuation
Patients on NMBA should
should be considered at least
receive lubricating eye drops as
daily.
they are at risk of corneal
abrasions.
 ARDS Evaluation Therapy

Assessment Critique

 Patient initiated sedative therapy with propofol, this  Analgesia treatment should have been started
agent cause hypertriglyceridemia (lipid emulsion). prior to sedation and NMBA.

 Midazolam was administered, since  Midazolam should have been started as

dexmedetomidine is not appropriate in patients with sedative treatment since the patient had high
NMBA as it does not cause deep sedation. triglyceride levels instead of Propofol.

 The patient started early therapy with NMBA and

with a PaO2/FiO2 ratio of <150 mmHg. This is
recommended since has been shown to improve
oxygenation.

 Patient received lubricating eye drops and

prophylactic therapy for DVT and PUD.
 Conclusions
Mercury is the closest planet to the Sun
and the smallest one in the Solar System
—it’s only a bit larger than our Moon.
The planet’s name has nothing to do
with the liquid metal, since it was
named after the Roman messenger god,
Mercury
 References
1. Bolesta S, Montgomery PA. Pancreatitis. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD,
Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw Hill; 2020. Accessed
November 29, 2021. https://accesspharmacy-mhmedical
2. Crockett SD, Wani S, Gardner TB, et al. American Gastroenterological Association Institute guideline
on initial management of acute pancreatitis. Gastroenterology. 2018;154(4):1096-1101.
doi:10.1053/j.gastro.2018.01.032 
3. Leppäniemi A, Tolonen M, Tarasconi A, et al. 2019 WSES guidelines for the management of severe
acute pancreatitis. World Journal of Emergency Surgery. 2019;14(1). doi:10.1186/s13017-019-0247-0 
4. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO
Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1–138.
5. Hoste EA, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat
Rev Nephrol. 2018;14(10):607-625. doi:10.1038/s41581-018-0052-0
6. Review analgesia and sedation in patients Ards - Springer.
https://link.springer.com/content/pdf/10.1007/s00134-020-06307-9.pdf. Accessed November 28, 2021.
7. SCCM: Padis guidelines. Society of Critical Care Medicine (SCCM).
https://www.sccm.org/ICULiberation/Guidelines. Accessed November 28, 2021. 
8. Meyer NJ, Gattinoni L, Calfee CS. Acute respiratory distress syndrome. The Lancet.
2021;398(10300):622-637. doi:10.1016/s0140-6736(21)00439-6 
 Our Team

Karla Yuret William Torres Angelie Ruiz

Pharm D. Candidate 2022 Pharm D. Candidate 2022 Pharm D. Candidate 2022
Thanks
Do you have any questions?

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