Systemic intravenous chemotherapeutic agents can cause multiple emergency situations including acute and chronic local and systemic reactions. Amongst them, drug extravasation is one of the most devastating complications, as many drugs can cause varying degrees of local tissue injury when extravasated. Although it is difficult to give an accurate measurement, the incidence of extravasation of systemic infusional chemotherapeutic agents has been reported to occur in 0.1-6.5% of cases. Since most extravasations can be prevented with the systematic implementation of careful administration techniques, guidelines have been published for the administration of vesicant drugs. The proper maintenance of intravenous lines, application of local cooling or warming for certain extravasations, and the use of antidotes to prevent the local toxic action of the extravasated drugs are the basis of medical management. The specific antidotes for certain chemotherapeutic agents are also discussed in this article.

Serotonin syndrome is an iatrogenic disorder induced by pharmacologic treatment with serotonergic agents that increases serotonin activity. In addition, there is a wide variety of clinical disorders associated with serotonin excess. The frequent concurrent use of serotonergic and neuroleptic drugs and similarities between serotonin syndrome and neuroleptic malignant syndrome can present the clinician with a diagnostic challenge. In this article, we review the pathophysiology, diagnosis, and treatment of serotonin syndrome as well as other serotonergic disorders.

Serotonin syndrome and other serotonergic disorders can cause a wide spectrum of symptoms. Because of the breadth of this spectrum, in our article, we endeavored to cover a wide range of topics related to this subject in a condensed manner that would provide useful and accurate information to clinicians. We agree with Dr. Gillman, who has done considerable work on this subject, that it is important for clinicians to understand the evolving nature of this field. In his letter, he presents additional studies published after the publication date of our article, which add to our information about serotonin and its effects. In addition, a substantial amount of information has been introduced to the clinical arena in the field of thrombocardiology, which is generally not of great interest to pain medicine specialists but in our article we suggest that interested parties should review these studies.The serotonergic disorders have a wide clinical spectrum not just composed of frank serotonin syndrome. As clinicians, we observe excess serotonin-related side effects and drug-drug interactions in our daily clinical practices. Although some of these symptoms are labeled as "nonserious" in nature in the above letter, we definitely do not share the same perspective, since serious disabling (i.e., extrapyramidal symptoms, tardive dyskinesia) events may occur, other than serotonin syndrome itself. In summary, we believe that our article provides a useful guide to clinicians, acknowledging that physicians need to update their knowledge periodically as new information emerges. We appreciate Dr. Gillman's perspective that brings attention to this rapidly evolving area of pain pharmacology.

No abstract