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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

The study aimed to investigate the association between the use of serotonergic antidepressants and blood transfusion requirements in orthopedic surgical patients.

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.

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.

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.

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.

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.

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.

To characterize the epidemiological profile, clinical features, and risk factors associated with fatal SS through a systematic review.

We performed a systematic review of MEDLINE and Google Scholar for case reports, case series, or cohort studies of fatal SS.

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.

While fatal SS is rare, frequently observed features include hyperthermia, seizures, and high CK activities. Cyproheptadine use appears infrequent for these patients.