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Sumie M, Cheng S, Niimi N, Englesakis M, Yang A, Adam RI, Pankiv E, Campisi P, Yamaura K, Hayes J, Aoyama K. Effect of ondansetron and metoclopramide on postoperative nausea and vomiting in children undergoing tonsillectomy with or without adenoidectomy: a systematic review with meta-analysis. J Anesth 2025; 39:345-354. [PMID: 39992376 DOI: 10.1007/s00540-025-03463-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Accepted: 02/02/2025] [Indexed: 02/25/2025]
Abstract
PURPOSE Postoperative nausea and/or vomiting (PONV/POV) following tonsillectomy occurs in up to 89% of children without antiemetic prophylaxis. Prior systematic reviews have not evaluated the relative efficacy of ondansetron and metoclopramide for PONV/POV, including their adverse effects. METHODS A systematic search was conducted of five databases from their inceptions to June 19, 2024. Inclusion criteria were randomized controlled trials (RCTs) comparing ondansetron and metoclopramide in pediatric patients undergoing tonsillectomy or adenotonsillectomy. The primary outcome was incidence of PONV/POV. Secondary outcomes were length of hospital stay (LOS) and adverse events including postoperative extrapyramidal reactions and delayed hospital readmissions. Pooled risk ratios (RRs) or mean differences (MDs) and 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Adjusted RRs were calculated using random-effects meta-regression. Risk of bias and certainty of evidence were assessed using Cochrane RoB 2 and GRADE, respectively. This study was registered in PROSPERO (42,024,499,702). RESULTS Five RCTs met all inclusion criteria, consisting of 861 patients. Ondansetron significantly reduced risk of PONV/POV by almost 50% (RR 0.48 95% CI 0.31-0.75, moderate quality evidence), compared to metoclopramide. Intraoperative opioid dose did not impact the RR. Ondansetron also significantly shortened LOS (MD - 26.92 min 95% CI - 47.24 min to - 6.60 min, moderate quality evidence). Only two RCTs addressed readmission rates or extrapyramidal reactions, although no events occurred in either study. CONCLUSION Ondansetron is more effective than metoclopramide for PONV/POV prophylaxis, decreasing the risk of PONV/POV as well as LOS. Continued surveillance for adverse effects may be recommended when using either medication.
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Affiliation(s)
- Makoto Sumie
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
- Program in Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
- Department of Anesthesiology, St. Mary's Hospital, Fukuoka, Japan
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sierra Cheng
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Naoko Niimi
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Alan Yang
- Program in Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada
| | | | - Evelina Pankiv
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
| | - Paolo Campisi
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Jason Hayes
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada
| | - Kazuyoshi Aoyama
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, 555 University Ave, #2211, Toronto, ON, M5G 1X8, Canada.
- Program in Child Health Evaluative Sciences, SickKids Research Institute, Toronto, ON, Canada.
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Kelly DM, Kelleher EM. Acute Febrile Encephalopathy with Rigidity. J Intensive Care Med 2025:8850666251345448. [PMID: 40448342 DOI: 10.1177/08850666251345448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2025]
Abstract
Febrile encephalopathy with rigidity can be the presenting feature of several life-threatening neurological emergencies such as neuroleptic malignant syndrome (NMS) and serotonin syndrome. Although the pathogenesis of these conditions is poorly understood, we review advances in our understanding of underlying genetic and other biological mechanisms. We also discuss the complex and expanding differential diagnoses which include other drug-induced hyperpyrexia or rigidity syndromes (eg malignant hyperthermia, parkinsonism-hyperpyrexia syndrome, malignant catatonia) as well as autoimmune syndromes. Finally, we consider potential predictive and preventative approaches along with best practice management strategies.
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Affiliation(s)
- Dearbhla M Kelly
- Oxford Critical Care, John Radcliffe Hospital, University of Oxford, Oxford, UK
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Eoin M Kelleher
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Rosenberg AE, Wang R, Rosenberg MH. Serotonin Syndrome Associated With High-dose Diphenhydramine Use Complicating Abdominoplasty and Mastopexy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2025; 13:e6634. [PMID: 40078625 PMCID: PMC11902954 DOI: 10.1097/gox.0000000000006634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 02/04/2025] [Indexed: 03/14/2025]
Abstract
Serotonin syndrome is a condition associated with increased serotonergic transmission in the central nervous system. Although shortfalls with diagnostic criteria have led to misleading associations with multiple medications, a possible precipitant is diphenhydramine. Documentation of such an association would prove important for physician practice, as diphenhydramine remains one of the most popular antihistamines available. We present a case of a 43-year-old woman who developed serotonin syndrome after bilateral mastopexy, miniabdominoplasty, and liposuction. The patient was on multiple serotonergic medications, including duloxetine, asenapine, and trazodone, in addition to high-dose diphenhydramine. Postoperatively, she developed tachycardia, leukocytosis, respiratory distress, and elevated lactate, initially leading to concerns of sepsis; however, further evaluation revealed the likely diagnosis of serotonin syndrome, triggered by the combination of serotonergic agents and intraoperative fentanyl. Management included an intensive care unit admission with discontinuation of serotonergic medications, administration of benzodiazepines, intravenous fluids, and norepinephrine for shock. The patient's condition improved for 36 hours, and she was discharged with adjustments to her psychiatric medications. This case contributes to the growing body of literature highlighting the risks of serotonin syndrome in patients on serotonergic polytherapy, particularly in the postoperative period. The interaction between our patient's chronic diphenhydramine abuse and multiple other serotonergic medications likely precipitated this condition. Preoperative medication reconciliation, early recognition of triggers and signs, and prompt intervention are key to preventing adverse outcomes in serotonin syndrome.
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Affiliation(s)
| | | | - Michael H. Rosenberg
- Department of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Chappaqua, NY
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Authors/Task Force Members:, Jeppsson A, (Co-Chairperson) (Sweden), Rocca B, (Co-Chairperson) (Italy), Hansson EC, (Sweden), Gudbjartsson T, (Iceland), James S, (Sweden), Kaski JC, (United Kingdom), Landmesser U, (Germany), Landoni G, (Italy), Magro P, (Portugal), Pan E, (Finland), Ravn HB, (Denmark), Sandner S, (Austria), Sandoval E, (Spain), Uva MS, (Portugal), Milojevic M, (Serbia), EACTS Scientific Document Group
. 2024 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2024; 67:ezae355. [PMID: 39385505 DOI: 10.1093/ejcts/ezae355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/14/2024] [Accepted: 09/26/2024] [Indexed: 10/12/2024] Open
Affiliation(s)
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Bianca Rocca
- Department of Medicine and Surgery, LUM University, Casamassima, Bari, Italy
- Department of Safety and Bioethics, Catholic University School of Medicine, Rome, Italy
| | | | - Emma C Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Stefan James
- Department of Medical Sciences, Uppsala University Uppsala Sweden
| | | | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's University of London, UK
| | | | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine; Deutsches Herzzentrum Charité, Campus Benjamin Franklin, Berlin, Germany
- Charité-University Medicine Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité Berlin, Universitätsmedizin Berlin, Germany
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Pedro Magro
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
| | | | - Emily Pan
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | | | - Hanne Berg Ravn
- Department of Anaesthesia, Odense University Hospital, Institute of Clinical Medicine, University of Southern, Denmark
| | | | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | | | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clinic, Barcelona, Spain
| | | | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Cardiovascular Research Centre, Department of Surgery and Physiology, Faculty of Medicine-University of Porto, Porto, Portugal
| | | | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
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Collaborators
Matthias Siepe, Vesa Anttila, Lauren Barron, Dobromir Dobrev, Fabio Guarracino, Ziad Hijazi, Andreas Koster, Tomislav Kostic, Vladimir Lomivorotov, Vojislava Neskovic, Bjorn Redfors, Lars Peter Riber, Andrea Székely, Juan Tamargo, Theis Tönnessen, Alicja Zientara,
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Lima G, Soares C, Teixeira M, Castelo-Branco M. Psychedelic research, assisted therapy and the role of the anaesthetist: A review and insights for experimental and clinical practices. Br J Clin Pharmacol 2024; 90:3119-3134. [PMID: 39380091 DOI: 10.1111/bcp.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/28/2024] [Accepted: 09/12/2024] [Indexed: 10/10/2024] Open
Abstract
Recent years have witnessed an unprecedented increase in the search for the use of psychedelics in improving physical and mental health. Anaesthesia has evolved since very early times, born from the need to eliminate pain and reduce suffering and there are reports of the use of anaesthetics to achieve mystical states since the nineteenth century. Nowadays, the renaissance of psychedelics in anaesthesia has been inspired by their potential in the treatment of chronic pain syndromes, palliative care and in the emergency department and pre-hospital care with the administration of psychedelics in cases of ischaemia, given their potential in neuroprotection. Although there are already some published protocols for the administration of psychedelics in patients with mental illness, little has been addressed concerning non-mental medical applications. In this sense, in patients with multiple comorbidities, functional limitations and polymedicated, the anaesthetist may play a fundamental role, not only in clinical practice, but also in translational research. This article focuses on the description of psychedelics, with a particular focus on dimethyltryptamine (DMT) and ayahuasca pharmacology, effects, safety and toxicity. A detailed description of the role of the anaesthetist in clinical and experimental research is provided, from participant's screening to preparation and dosing session, expected adverse effects and how to manage them, based on the protocol and standard procedures of a current study with neuroimaging during the psychedelic experience. Specific considerations regarding the management of psychedelic toxicity are also provided as well as future directions for safe psychedelic use in clinical practice.
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Affiliation(s)
- Gisela Lima
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, Coimbra, Portugal
- Institute of Nuclear Sciences Applied to Health (ICNAS), Coimbra, Portugal
- Faculty of Medicine (FMUC), University of Coimbra, Coimbra, Portugal
| | - Carla Soares
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, Coimbra, Portugal
- Institute of Nuclear Sciences Applied to Health (ICNAS), Coimbra, Portugal
- Faculty of Medicine (FMUC), University of Coimbra, Coimbra, Portugal
| | - Marta Teixeira
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, Coimbra, Portugal
- Institute of Nuclear Sciences Applied to Health (ICNAS), Coimbra, Portugal
| | - Miguel Castelo-Branco
- Coimbra Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, Coimbra, Portugal
- Institute of Nuclear Sciences Applied to Health (ICNAS), Coimbra, Portugal
- Faculty of Medicine (FMUC), University of Coimbra, Coimbra, Portugal
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Majumdar S, Dammalapati PK, Kar SK, Sanki PK, Dasgupta CS. Bronchial carcinoid: a neuroendocrine manifestation-presented as bronchospasm and hypertension during resection. Indian J Thorac Cardiovasc Surg 2024; 40:603-607. [PMID: 39156057 PMCID: PMC11329453 DOI: 10.1007/s12055-024-01689-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 08/20/2024] Open
Abstract
Bronchopulmonary carcinoid tumors are rare, slow-growing malignant neuroendocrine tumors. Early diagnosis is pivotal as surgical resection is the main stay of treatment. A 40-year-old female with typical bronchial carcinoid presented with complaints of breathlessness on mild to moderate exertion, intermittent productive cough, low-grade fever, and loss of appetite since 1 year. Right lobectomy was performed with regional lymph node resection; during resection of the tumor, manipulation led to a massive surge and fluctuations in blood pressure which were managed with deepening of the plane of anesthesia and administration of nitroglycerin infusion. She was discharged home in a good condition. Typical carcinoid tumor involves the central airways causing bronchial obstruction; however, in the present case, non-specific symptomatic presentation led to late detection. The outcome of typical carcinoids even with lymph node metastasis is excellent with complete resection; however, close follow-up is recommended due to a high incidence of recurrence.
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Affiliation(s)
- Sohini Majumdar
- Department of Cardiac Anaesthesiology, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
| | - Pavan Kumar Dammalapati
- Department of Cardiac Anaesthesiology, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
| | - Sandeep Kumar Kar
- Department of Cardiac Anaesthesiology, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
| | - Prakash Kumar Sanki
- Department of Cardio Thoracic Vascular Surgery, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
| | - Chaitali Sen Dasgupta
- Department of Cardiac Anaesthesiology, Institute of Post Graduate Medical Education and Research (IPGMER), Kolkata, India
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Prakash S, Shah CS, Prakash A. Serotonin syndrome controversies: A need for consensus. World J Crit Care Med 2024; 13:94707. [PMID: 38855279 PMCID: PMC11155509 DOI: 10.5492/wjccm.v13.i2.94707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/26/2024] [Accepted: 05/11/2024] [Indexed: 06/03/2024] Open
Abstract
Serotonin syndrome (SS) is a drug-induced clinical syndrome resulting from increased serotonergic activity in the central nervous system. Although more than seven decades have passed since the first description of SS, it is still an enigma in terms of terminology, clinical features, etiology, pathophysiology, diagnostic criteria, and therapeutic measures. The majority of SS cases have previously been reported by toxicology or psychiatry centers, particularly in people with mental illness. However, serotonergic medications are used for a variety of conditions other than mental illness. Serotonergic properties have been discovered in several new drugs, including over-the-counter medications. These days, cases are reported in non-toxicology centers, such as perioperative settings, neurology clinics, cardiology settings, gynecology settings, and pediatric clinics. Overdoses or poisonings of serotonergic agents constituted the majority of the cases observed in toxicology or psychiatry centers. Overdose or poisoning of serotonergic drugs is uncommon in other clinical settings. Patients may develop SS at therapeutic dosages. Moreover, these patients may continue to use serotonergic medications even if they develop mild to moderate SS due to several reasons. Thus, the clinical presentation (onset, severity, and clinical features) in such instances may not exactly match what toxicologists or psychiatrists observe in their respective settings. They produce considerable diversity in many aspects of SS. However, other experts discount these new developments in SS. Since SS is a potentially lethal illness, consensus is required on several concerns related to SS.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara 391760, Gujarāt, India
| | - Chetsi S Shah
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara 391760, Gujarāt, India
| | - Anurag Prakash
- Medicine, Parul Institute of Medical Sciences and Research Centre, Parul University Waghodia, Vadodara 391760, India
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Srifuengfung M, Abraham J, Avidan MS, Lenze EJ. Perioperative Anxiety and Depression in Older Adults: Epidemiology and Treatment. Am J Geriatr Psychiatry 2023; 31:996-1008. [PMID: 37482501 PMCID: PMC10592367 DOI: 10.1016/j.jagp.2023.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 06/20/2023] [Accepted: 07/03/2023] [Indexed: 07/25/2023]
Abstract
The intervals before and after major surgery is a high-risk period for older adults; in this setting, anxiety and depression are common and serious problems. We comprehensively reviewed current evidence on perioperative anxiety and depression in older adults, focusing on epidemiology, impact, correlates, medication risks, and treatment. Principles of perioperative mental healthcare are proposed based on the findings. Prevalence estimates of clinically significant anxiety and depression range from 5% to 45% for anxiety and 6% to 52% for depression, depending on surgical populations and measurement tools. Anxiety and depression may increase risk for surgical complications and reduce patient participation during rehabilitation. Medical comorbidities, pain, insomnia, cognitive impairment, and delirium are common co-occurring problems. Concomitant uses of central nervous system acting medications (benzodiazepines, anticholinergics, and opioids) amplify the risks of delirium and falls. Based on these findings, we propose that anxiety and depression care should be part of perioperative management in older adults; components include education, psychological support, opioid-sparing pain management, sleep management, deprescribing central nervous system active medications, and continuation and optimization of existing antidepressants. More research is needed to test and improve these care strategies.
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Affiliation(s)
- Maytinee Srifuengfung
- Department of Psychiatry (MS, EJL), Washington University School of Medicine, St. Louis, MO; Department of Psychiatry (MS), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Joanna Abraham
- Department of Anesthesiology (JA, MSA), Washington University School of Medicine, St. Louis, MO; Institute for Informatics (JA), Washington University School of Medicine, St. Louis, MO
| | - Michael S Avidan
- Department of Anesthesiology (JA, MSA), Washington University School of Medicine, St. Louis, MO
| | - Eric J Lenze
- Department of Psychiatry (MS, EJL), Washington University School of Medicine, St. Louis, MO
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Iqbal F, Narayan A, Chatrath M, Iqbal M. Examining the Association Between Serotonergic Antidepressants and Blood Transfusion Requirements in Orthopaedic Surgery: A Comprehensive Analysis. Cureus 2023; 15:e45988. [PMID: 37900430 PMCID: PMC10601511 DOI: 10.7759/cureus.45988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
AIM The study aimed to investigate the association between the use of serotonergic antidepressants and blood transfusion requirements in orthopedic surgical patients. METHODOLOGY A retrospective follow-up study was conducted at Kota Trauma Hospital, Kota, Rajasthan focusing on patients who underwent orthopedic surgeries between November 2021 through December 2022. Patients were categorized into two groups: users of serotonergic antidepressants and users of other antidepressants (non-selective serotonergic antidepressants). The requirement for blood transfusion for both groups was assessed. Covariate factors, such as medication use and comorbidities (e.g., diabetes mellitus, cardiovascular diseases), were examined to control potential confounding variables. RESULT A total of 170 subjects with complete medical records were included in the study. The results presented a significant association between the usage of serotonergic antidepressants and blood transfusion requirements (p=0.001). While no significant differences between the two groups were observed in perioperative hemoglobin levels and fluid infusion, there was a significant difference in blood loss and postoperative drainage. CONCLUSION Serotonergic antidepressant usage was correlated with increased blood transfusion requirements in orthopedic surgery patients on antidepressants. The study underscores the importance of considering medication factors in perioperative management and highlights potential implications for patient care strategies.
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Affiliation(s)
- Faiez Iqbal
- Orthopaedics and Trauma, Kota Trauma Hospital, Kota, IND
| | | | | | - Mohammad Iqbal
- Orthopaedics and Trauma, Kota Trauma Hospital, Kota, IND
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Hölle T, Purrucker JC, Morath B, Weigand MA, Schmitt FCF. [Central anticholinergic, neuroleptic malignant and serotonin syndromes]. WIENER KLINISCHES MAGAZIN : BEILAGE ZUR WIENER KLINISCHEN WOCHENSCHRIFT 2023; 26:124-132. [PMID: 37251531 PMCID: PMC10123475 DOI: 10.1007/s00740-023-00492-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.
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Affiliation(s)
- Tobias Hölle
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Jan C. Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Benedict Morath
- Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A. Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Felix C. F. Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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Hölle T, Purrucker JC, Morath B, Weigand MA, Schmitt FCF. [Central anticholinergic, neuroleptic malignant and serotonin syndromes : Important differential diagnoses in postoperative impairment of consciousness]. DIE ANAESTHESIOLOGIE 2023; 72:157-165. [PMID: 36799968 PMCID: PMC9936123 DOI: 10.1007/s00101-023-01256-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 02/18/2023]
Abstract
Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.
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Affiliation(s)
- Tobias Hölle
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Jan C. Purrucker
- grid.5253.10000 0001 0328 4908Neurologische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Benedict Morath
- grid.5253.10000 0001 0328 4908Krankenhausapotheke, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A. Weigand
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
| | - Felix C. F. Schmitt
- grid.5253.10000 0001 0328 4908Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Deutschland
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Jooma Z. Drug interactions. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Administration of multiple drugs within a short period of time is inevitable in anaesthesia practice, increasing the likelihood of drug interactions with each drug or with patients’ chronic medication. Drug interactions can be described as the pharmacological effect of one drug on another drug when administered simultaneously. The principles of these interactions may be divided into pharmaceutical, which relates to the physicochemical structure or pharmaceutical preparation of a drug; pharmacokinetic (PK), which relates to changes in drug handling in the body; or pharmacodynamic (PD) where drug activity is affected.
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Affiliation(s)
- Z Jooma
- University of the Witwatersrand
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Prakash S, Rathore C, Rana K, Prakash A. Fatal serotonin syndrome: a systematic review of 56 cases in the literature. Clin Toxicol (Phila) 2020; 59:89-100. [PMID: 33196298 DOI: 10.1080/15563650.2020.1839662] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Serotonin syndrome (SS) is a drug-induced potentially life-threatening clinical condition. There is a paucity of data on the risk factors, clinical course, and complications associated with fatal SS. OBJECTIVE To characterize the epidemiological profile, clinical features, and risk factors associated with fatal SS through a systematic review. METHODS We performed a systematic review of MEDLINE and Google Scholar for case reports, case series, or cohort studies of fatal SS. RESULTS Initial database search identified 2326 articles of which 46 (56 patients) were included in the final analysis. The mean age was 42.3 years (range 18-87 years) with female predominance (57%). North America and Europe constitute 80% of the reported fatal SS. The symptoms evolved very rapidly, within 24 h after the administration of serotonergic drugs in 59% of the cases. Fever (61%) was the most common symptom, followed by seizure (36%) and tremors (30%). The mean temperature in the reported cases (25 patients) was 41.6 ± 1.3 °C (range 38.3-43.5 °C). SS was reported to occur with the maintenance dosage of serotonergic agents, after initiation of the drug for the first time, and addition of the drugs for the development of another unrelated illness. Creatine kinase (CK) activities were elevated (>3 times of the upper limit of normal) in eighteen patients, and it was very high (>25,000 IU/L) in four patients. Presence of high grade fever, seizures, and high CK activities may be associated with severe SS. Nine patients (16%) received 5-HT2A antagonists as a therapy. About 50% of patients died within 24 h of the onset of symptoms. CONCLUSIONS While fatal SS is rare, frequently observed features include hyperthermia, seizures, and high CK activities. Cyproheptadine use appears infrequent for these patients.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Kaushik Rana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Anurag Prakash
- Parul Institute of Medical Sciences & Research, Parul University, Waghodia, Vadodara, India
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Thomas E, Martin F, Pollard B. Delayed recovery of consciousness after general anaesthesia. BJA Educ 2020; 20:173-179. [PMID: 33456947 PMCID: PMC7807841 DOI: 10.1016/j.bjae.2020.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2020] [Indexed: 01/13/2023] Open
Affiliation(s)
- E. Thomas
- Stepping Hill Hospital, Stockport, UK
| | - F. Martin
- Health Education England-North West, Manchester, UK
| | - B. Pollard
- University of Manchester, Manchester, UK
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