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To evaluate the impact of an opioid-sparing pain management protocol on overall opioid consumption and clinical outcomes.This was a single-center, quasi-experimental, retrospective, before and after cohort study. We used an interrupted time series to analyze changes in the levels and trends of the utilization of different analgesics. We used bivariate comparisons in the before and after cohorts as well as logistic regression and quantile regression for adjusted estimates.We included 988 patients in the preintervention period and 1,838 in the postintervention period. Fentanyl consumption was slightly increasing before the intervention (β = 16; 95%CI 7 - 25; p = 0.002) but substantially decreased in level with the intervention (β = - 128; 95%CI -195 - -62; p = 0.001) and then progressively decreased (β = - 24; 95%CI -35 - -13; p0.001). There was an increasing trend in the utilization of dipyrone. The mechanical ventilation duration was significantly lower (median difference: - 1 day; 95%CI -1 - 0; p0.001), especially for patients who were mechanically ventilated for a longer time (50th percentile difference: -0.78; 95%CI -1.51 - -0.05; p = 0.036; 75th percentile difference: -2.23; 95%CI -3.47 - -0.98; p0.001).A pain management protocol could reduce the intensive care unit consumption of fentanyl. This strategy was associated with a shorter mechanical ventilation duration.Avaliar o impacto de um protocolo de manejo da dor e redução do consumo de opioides no consumo geral de opioides e nos desfechos clínicos.Estudo em centro único, quasi-experimental, retrospectivo, de coortes antes e depois. Utilizamos uma série temporal interrompida para analisar as alterações no nível e na tendência de utilização de diferentes analgésicos. Foram usadas comparações bivariadas nas coortes antes e depois, regressão logística e regressão quantílica para estimativas ajustadas.Incluímos 988 pacientes no período pré-intervenção e 1.838 no período pós-intervenção. O consumo de fentanil teve ligeiro aumento gradual antes da intervenção (β = 16; IC95% 7 - 25; p = 0,002), porém diminuiu substancialmente em nível com a intervenção (β = - 128; IC95% -195 - -62; p = 0,001) e, a partir de então, caiu progressivamente (β = - 24; IC95% -35 - -13; p0,001). Houve tendência crescente de utilização de dipirona. A duração da ventilação mecânica foi significantemente menor (diferença mediana: - 1 dia; IC95% -1 - 0; p0,001), especialmente para pacientes mecanicamente ventilados por períodos mais longos (diferença no 50º percentil: -0,78; IC95% -1,51 - -0,05; p = 0,036; diferença no 75º percentil: -2,23; IC95% -3,47 - -0,98; p0,001).Um protocolo de manejo da dor conseguiu reduzir o consumo de fentanil na unidade de terapia intensiva. Esta estratégia se associou com menor duração da ventilação mecânica.

Summary of the case report and SBP as a novelinfection in OHSS We presented a patient with serious illness due to OHSS.Some laboratory findings for our patient were characteristicof severe OHSS, including leukocytosis (white blood cellcount .15,000), electrolyte imbalances (hyponatremia:sodium ,135 mEq/L), and elevated liver enzymes. 1 Theevolution of this condition was complicated by theoccurrence of SBP due to E. coli, which was successfullytreated with antibiotics and intravenous human albuminadministration.SBP is characterized by the spontaneous infection ofascitic fluid in the absence of an intraabdominal source ofinfection. 12 The occurrence of peritonitis associated withOHSS was the subject of a previous case report, but in thatcase, the infection was due to perforated appendicitis. 13 Noprevious report of an association between SBP and OHSSwas found. Therefore, the occurrence of this infectiouscomplication during OHSS appears to be novel. The occurrence of SBP in OHSS The most important aspect of our case report is theevidence of SBP as a cause of sepsis during OHSS. Thepresence of .250 PMN cells/mm

ST-segment elevation, observed in the critically ill patients, almost always raises the suspicion of ischemic heart disease. However, nonischemic myocardial and non-myocardial problems in these patients may also lead to ST-segment elevation. Pneumothorax and pneumopericardium have been rarely reported as a cause of transient ST-segment elevation. The authors report the case of a patient admitted to the emergency care unit because of a respiratory failure requiring mechanical ventilatory support. As the patient showed signs of clinical deterioration, a pneumothorax was clinically diagnosed. Chest radiography after thorax drainage also disclosed a pneumopericardium. The 12-lead electrocardiogram recorded before the thoracic drainage revealed an ST-segment elevation, which normalized after the surgical procedure. Ischemic myocardial biomarkers were negative. The authors call attention to the right-sided pneumothorax associated with pneumopericardium as an unusual cause of ST-segment elevation.