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Initial Patient Presentation and Assessment
A 56-year-old white female who has chest pains collapsed at home. She was evaluated by paramedics and discovered to be in ventricular fibrillation, was successfully cardioverted with 200 joules, and brought to the tertiary hospital.

A few days prior to presentation, she had received news that her son had passed away while on active duty in the military.

Her previous medical history includes a diagnosis of left breast cancer 4 years ago, for which she received chemotherapy and radiation. She also has a history of gastroesophageal reflux disease, hyperlipidemia, and remote episodes of gastritis. She has no surgical history or known drug allergies.

Emergency Department Presentation and Treatment
Additional tests were ordered at the hospital, including an electrocardiogram, cardiac enzymes, and chest X-ray. The patient was taken to the electrophysiology laboratory for cardiac catheterization and intubated secondary to severe nausea and vomiting. She was hemodynamically unstable with severe hypotension and initiated on multiple vasopressors.

Her physical examination and vitals included the following:
  • Weight: 130 lbs
  • Height: 5’4”
  • Heart rate: 109 bpm
  • Blood pressure: 74/34 mm Hg
  • Temperature: 98.5°F
  • O2 saturation: 96%
  • External examination: not remarkable

Diagnosis and Patient Course
The patient is diagnosed with left ventricular failure and takotsubo cariomyopathy based on Swan-Ganz catheter value, diffuse ST-segment elevation, S3 sound gallop, and pulmonary congestion. A left ventricular-assist device (LVAD) is implanted on the same day (day 1) after failing to maintain blood pressure on multiple pressors. Over the course of the day vasopressors are weaned and patient is extubated in 2 days.

On day 5, the patient is anemic (drifting hemoglobin currently 7.1 g/dL) and complains of weakness. To investigate recovery, the LVAD was turned off for 30 minutes while the patient was on full-dose heparin. Without mechanical support, the left ventricular end-diastolic dimension was 56 mm and left ventricular function was normal, except for septal akinesia.

The clinician plans to explant the LVAD at 1 month, after a second investigation including hemodynamic measurements and exercise performance.

Gastric bleed is suspected and esophagogastroduodenoscopy (EGD) under sedation is planned. Sedation options are discussed.

Pre-Endoscopy Evaluation
Current medications include:
  • Pantoprazole 40 mg daily
  • Carvedilol 25 mg twice daily
  • Enalapril 5 mg twice daily
  • Aspirin 100 mg daily
  • Heparin drips titrated per ventricular-assist device (VAD) protocol

Relevant laboratory results include:
  • Hemoglobin 7.1 gm/dL
  • Brain natriuretic peptide plasma level
    • 11 pmol/L with support
    • 13 pmol/L without support
  • Serum electrolyte levels within normal limits


Which of the following would be the MOST appropriate level of sedation during endoscopy for this patient?




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