LM and LAD artery ectasia with fistula to right ventricle was treated with fistula outflow closure only and long-term anticoagulation.See Commentaries on pages 73 and 75.
Background: This study aimed to evaluate the effect of low-dose ketamine pretreatment to etomidate on serum cortisol levels in critically ill cardiac patients with acute anemia undergoing upper endoscopy and ColonoscopyPatients and Methods: Sixty adult cardiac patients, ≥ 18 years, who underwent upper endoscopy and Colonoscopy to manage acute anemia in the cardiac intensive care units were enrolled. Patients were randomly divided into two groups: Group (E): received etomidate 0.2 mg/kg IV followed by etomidate 0.05 mg/kg IV, and Group (KE): received ketamine 0.5 mg/kg IV, then etomidate 0.1 mg/kg IV, followed by etomidate 0.05 mg/kg IV. The primary outcome was Serum cortisol level at 6 hours after the procedure. The secondary outcomes: Estimated change in serum cortisol level (6-hours postoperative value compared to preoperative one), the incidence of any adverse effects, patient satisfaction, and total etomidate dose. Results: The mean postoperative cortisol level significantly reduced in group E than group KE; (295.60±49.218) mcg/dL versus (461.00 ±67.946) mcg/dL respectively With 95% CI = 351.94 to 404.66. In addition, the estimated serum cortisol reduction level was also significant between groups; In group E, the estimated cortisol level decreased nearly 53% from 632.40±35.066 mcg/dL to 295.60±49.218 mcg/dL six hours postoperative. While in group KE, the estimated cortisol level decreased only 27% from 639.13±43.035 mcg/dL to 461.00±67.946 mcg/dL.Conclusions: low-dose ketamine pretreatment to etomidate can successfully control etomidate-induced adrenocortical suppression and minimize the decrease in serum cortisol level in critically ill cardiac patients with no additional adverse effects.Trial Registration: This study is registered on ClinicalTrials.gov (NCT04857450; principal investigator: Mostafa Mohammed Elsaid Elhamamsy; registration date: 23/04/ 2021).
We describe a case of hybrid total thoracic aortic repair and valve-in-valve transcatheter aortic valve replacement in a high-risk patient with complicated chronic type A dissection and severe prosthetic aortic stenosis. The patient underwent a three-stage-procedure including aortic arch debranching, thoracic endovascular aortic repair of the ascending aorta, aortic arch and descending thoracic aorta, and direct aortic valve-in-valve replacement using transcatheter heart valve. The details of the procedures are described with a discussion of the challenges and the decision-making process.
Background
Etomidate was associated with an inhibition of adrenal steroid synthesis. This study aimed to evaluate the effects of adding low-dose ketamine to etomidate to minimize the decrease in serum cortisol level in critically ill cardiac patients.
Methods
Sixty adult cardiac patients, ≥ 18 years, who underwent upper endoscopy and Colonoscopy to manage acute anemia in the cardiac intensive care units were enrolled. Patients were randomly divided into two groups: (group (E): n = 30) received etomidate 0.2 mg/kg IV followed by etomidate 0.05 mg/kg IV, and (group (KE): n = 30) received ketamine 0.5 mg/kg IV, then etomidate 0.1 mg/kg IV, followed by etomidate 0.05 mg/kg IV. The primary outcome was Serum cortisol level at 6 h after the procedure.
Results
The mean postoperative cortisol level was significantly lower in group E (295.60 ± 49.218 nmol/L) versus group KE (461.00 ± 67.946 nmol/L), with 95% CI = 351.94 to 404.66; p = 0.000. In addition, the estimated serum cortisol reduction level was also significant between groups; In group E, the estimated cortisol level decreased nearly 53% from 632.40 ± 35.066 nmol/L to 295.60 ± 49.218 nmol/L 6 hours postoperative. While in group KE, the estimated cortisol level decreased only 27% from 639.13 ± 43.035 nmol/L to 461.00 ± 67.946 nmol/L.
Conclusions
Single-dose ketamine (0.5 mg/kg) was helpful to decrease the total dose of etomidate and hence decreased the percentage of serum cortisol level in such critically ill patients with preservation of patient satisfaction.
Trial Registration
This study is registered on ClinicalTrials.gov (NCT04857450; principal investigator: Mostafa Mohammed Elsaid Elhamamsy; registration date: 23/04/ 2021).
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