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).

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.