Randomized Controlled Trial of Ketamine and Moderate Sedation for Outpatient Endoscopy in Adults.

INTRODUCTION: Ketamine is an effective sedative agent in a variety of settings due to its desirable properties including preservation of laryngeal reflexes and lack of cardiovascular depression. We hypothesized that ketamine is an effective alternative to standard moderate sedation (SMS) regimens for patients undergoing endoscopy. MATERIALS AND METHODS: We conducted a randomized controlled trial comparing ketamine to SMS for outpatient colonoscopy or esophagogastroduodenoscopy at Brooke Army Medical Center. The ketamine group received a 1-mg dose of midazolam along with ketamine, whereas the SMS group received midazolam/fentanyl. The primary outcome was patient satisfaction measured using the Patient Satisfaction in Sedation Instrument, and secondary outcomes included changes in hemodynamics, time to sedation onset and recovery, and total medication doses. RESULTS: Thirty-three subjects were enrolled in each group. Baseline characteristics were similar. Endoscopies were performed for both diagnostic and screening purposes. Ketamine was superior in the overall sedation experience and in all analyzed categories compared to the SMS group (P = .0096). Sedation onset times and procedure times were similar among groups. The median ketamine dose was 75 mg. The median fentanyl and midazolam doses were 150 mcg and 5 mg, respectively, in SMS. Vital signs remained significantly closer to the physiological baseline in the ketamine group (P = .004). Recovery times were no different between the groups, and no adverse reactions were encountered. CONCLUSIONS: Ketamine is preferred by patients, preserves hemodynamics better than SMS, and can be safely administered by endoscopists. Data suggest that ketamine is a safe and effective sedation option for patients undergoing esophagogastroduodenoscopy or colonoscopy (clinicaltrials.gov NCT03461718).

Severe acute liver injury associated with Yersinia enterocolitica.

Yersinia enterocolitica is a Gram-negative bacterium that causes foodborne illnesses, typically characterised by acute febrile gastroenteritis and is associated with a variety of manifestations. Isolated febrile illness without gastrointestinal symptoms is rare. We report a case of Y. enterocolitica infection with severe anicteric hepatitis. A 33-year-old Chinese man with no significant medical history presented on multiple occasions to the emergency department with recurrent high-grade fever and chills, but without gastrointestinal symptoms. Hepatic panel showed rising transaminases that peaked at Aspartate Aminotransferase (AST) of 991 U/L and Alanine Aminotransferase (ALT) of 1664 U/L. CT of the abdomen revealed terminal ileitis and mesenteric adenitis. As part of workup, we found positive serology for Y. enterocolitica Ultimately, he improved with supportive care. This case highlights the importance of thorough workup of terminal ileitis and 'Crohn's mimics' which ultimately revealed a unifying diagnosis; and an important addition to the workup for undifferentiated severe isolated hepatocellular liver injury.

Estimation of cardiac risk before noncardiac surgery: the evolution of cardiac risk indices.

Postoperative cardiac complications are among the most feared events in patients undergoing noncardiac surgery. Hospitalists, internists, cardiologists, and anesthesiologists are frequently asked to provide preoperative consultations to assess risk and optimize medical treatment for the patient. Over the years, numerous studies have attempted to define preoperative risk factors in an attempt to risk stratify patients and determine when interventions may be applied to reduce risk. These studies have proposed various risk indices and algorithms based on identification of different risk factors, related to variations in patient populations, types of surgery, definitions of comorbidities, and endpoints studied. This article reviews many of these risk indices, highlighting their findings, utilities, and limitations.

New development of cardiac tamponade on underlying effusive-constrictive pericarditis: an uncommon initial presentation of scleroderma.

A 40-year-old man with a medical history of hypertension was admitted for weight loss, generalised weakness, joint pains and mottling of fingertips. The initial laboratory data revealed microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure. Intravenous steroids were started for possible diagnosis of systemic lupus erythematosus based on admission assessment. Intravenous immunoglobulin and plasmapharesis were subsequently added to the treatment plan to cover thrombotic thrombocytopenic purpura while his autoimmune panel was pending. The echocardiogram study on day 2 revealed cardiac tamponade for which he underwent pericardiocentesis and right heart catheterisation. The atrial waveforms postpericardiocentesis demonstrated effusive-constrictive pericarditis. His clinical condition kept on deteriorating with reaccumulation of pericardial effusion and further complicated by hemoperitoneum and colonic obstruction. He had cardiorespiratory arrest on his fourth admission day and was not revived. Anti-Scl-70 antibody came back positive. Autopsy findings confirmed the presence of fibrinous pericarditis and hemoperitoneum.

Aborted sudden cardiac death (SCD) in a patient with hypertrophic cardiomyopathy (HCM) with low-risk factors for SCD.

Remarkable advancements have been made in understanding the pathophysiology of hypertrophic cardiomyopathy (HCM), since the first implantable cardioverter defibrillator (ICD) was placed in a human, more than 25 years ago to prevent sudden cardiac death (SCD). ICD has become the cornerstone in the management of HCM, with an ability to change the natural course of this complex disease. American College of Cardiology/American Heart Association guidelines have been charted out to help risk stratify asymptomatic or minimally symptomatic adults with HCM, in order to prevent SCD in such individuals. Our patient with left ventricular outflow tract gradient <30 mm Hg, left ventricular wall thickness < 30 mm, negative medical history of syncope and no family history of SCD, would have been at low risk for SCD.