Serotonin syndrome (SS) is a life-threatening condition caused by excessive serotonin, typically due to drugs such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and certain opioids. It often results from combining two serotonin-affecting drugs or excessive use of one. SS is diagnosed clinically, presenting with neuromuscular hyperactivity, autonomic instability, and altered mental status, with clonus as a key distinguishing feature. The Hunter Criteria aids diagnosis but should not be used to rule out SS. Treatment starts with discontinuing the offending agent, followed by supportive care, including airway management and stabilization of vital signs. Benzodiazepines can help control seizures and agitation, while cyproheptadine may be used in moderate to severe cases. Benzodiazepines have many side effects and cyproheptadine is only available in oral formulations, which adds complexity to effective treatment. In rare instances, SS can be refractory and may require intubation and neuromuscular paralytics. In this case, we present a case of a 42-year-old female who developed confusion, tachycardia, muscle rigidity, and hypertension after outpatient ankle surgery, where she received midazolam, fentanyl, propofol, toradol, ondansetron, meperidine, and dexamethasone perioperatively. Her daily medication also included fluoxetine, dextroamphetamine-amphetamine, and trazodone. The patient required intubation for continued diazepam administration and was admitted to the ICU. Despite improving vital signs, she remained altered with diffuse muscle rigidity. After three days of refractory SS, dexmedetomidine, an alpha-2 antagonist, was administered. The patient showed clinical improvement over the next four days and was stable enough for extubation and discontinuation of dexmedetomidine. The patient made significant clinical progress and was discharged to follow up with her primary care provider. This case highlights the importance of early detection through clinical context and not relying solely on the Hunter criteria and the potential use of dexmedetomidine as an adjuvant to benzodiazepine therapy.

2025-02-01·The Annals of Thoracic Surgery

Cardiac Surgical Bleeding, Transfusion, and Quality Metrics: Joint Consensus Statement by the Enhanced Recovery After Surgery Cardiac Society and Society for the Advancement of Patient Blood Management

Review

作者: Patel, Prakash A ; Arora, Rakesh C. ; Ozawa, Sherri ; Shore-Lesserson, Linda ; Rosengart, Todd K ; Grant, Michael C. ; Engelman, Daniel T ; D'Oria, Mario ; Arora, Rakesh C ; Patel, Prakash A. ; Raphael, Jacob ; Evans, Caroline ; Rosengart, Todd K. ; Gunaydin, Serdar ; Morton, Vicki ; Engelman, Daniel T. ; Bracey, Arthur ; Shander, Aryeh ; Salenger, Rawn ; D’Oria, Mario ; Grant, Michael C ; Tibi, Pierre

BACKGROUNDExcessive perioperative bleeding is associated with major complications in cardiac surgery, resulting in increased morbidity, mortality, and cost.METHODSAn international expert panel was convened to develop consensus statements on the control of bleeding and management of transfusion and to suggest key quality metrics for cardiac surgical bleeding. The panel reviewed relevant literature from the previous 10 years and used a modified RAND Delphi methodology to achieve consensus.RESULTSThe panel developed 30 consensus statements in 8 categories, including prioritizing control of bleeding, prechest closure checklists, and the need for additional quality indicators beyond reexploration rate, such as time to reexploration. Consensus was also reached on the need for a universal definition of excessive bleeding, the use of antifibrinolytics, optimal cessation of antithrombotic agents, and preoperative risk scoring based on patient and procedural factors to identify those at greatest risk of excessive bleeding. Furthermore, an objective bleeding scale is needed based on the volume and rapidity of blood loss accompanied by viscoelastic management algorithms and standardized, patient-centered blood management strategies reflecting an interdisciplinary approach to quality improvement.CONCLUSIONSPrioritizing the timely control and management of bleeding is essential to improving patient outcomes in cardiac surgery. To this end, a cardiac surgical bleeding quality metric that is more comprehensive than reexploration rate alone is needed. Similarly, interdisciplinary quality initiatives that seek to implement enhanced quality indicators will likely lead to improved patient care and outcomes.

2024-07-27·Cureus

A Case of Cameron Lesions: An Overlooked Cause of Anemia in Patients With Gastrointestinal Bleeding and Hiatal Hernia

Article

作者: Le, Pham Thao Vy ; Tran, Khoa N ; Nguyen, Hong Thoai ; Vo, Quynh Chau ; Dang, Chau

Cameron lesions are rare causes of upper gastrointestinal bleeding (UGIB). The lesions are linear erosions or ulcers that develop in the sac of a hiatal hernia, which often go unnoticed in the upper gastrointestinal system, and are a prevalent cause of anemia resulting from iron deficiency. Postponed treatment can result in severe consequences such as potentially fatal hemorrhaging. Here, we present a case of a young woman who presented to the emergency room with recurrent gastrointestinal bleeding and severe microcytic anemia. The chest X-ray revealed a partial intrathoracic stomach, and a large hiatal hernia was subsequently confirmed in the CT scan of the abdomen and pelvis. The esophagogastroduodenal endoscopy indicated Los Angeles Classification System grade A reflux esophagitis and an 8 cm hiatal hernia with multiple Cameron ulcers with pigmented material and chronic non-erosive gastritis. Biopsies of the gastric body and antrum showed Helicobacter pylori-associated chronic active gastritis and intestinal metaplasia. An esophagus biopsy showed squamous esophageal mucosa with mild chronic inflammation. The patient was treated with a transfusion of three units of red blood cells, iron replenishment, and pantoprazole infusion and underwent hiatal hernia repair with mesh and Toupet fundoplication without any complications. After that, the patient was discharged and scheduled for follow-up with general surgery at the outpatient clinic.

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