antidepressants AND perioperative

perioperative management antidepressants anaesthesia serotonin syndrome MAO inhibitors guidance

https://www.openanesthesia.org/keywords/mao-inhibitors-anest…

~/

mkdir -p "/tmp/workspace/antidepressants-anaesthesia/output"  python - <<'PY' from reportlab.lib.pagesizes import A4 from reportlab.lib import colors from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle from reportlab.lib.enums import TA_CENTER from reportlab.platypus import SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle, PageBreak, KeepTogether from reportlab.lib.units import cm from reportlab.pdfbase.ttfonts import TTFont from reportlab.pdfbase import pdfmetrics from reportlab.lib.colors import HexColor from reportlab.pdfbase.pdfmetrics import stringWidth from reportlab.pdfgen import canvas from reportlab.lib.colors import black out='/tmp/workspace/antidepressants-anaesthesia/output/Antidepressants_in_Anaesthesia_Quick_Reference.pdf' navy=HexColor('#17365D'); blue=HexColor('#DCE6F1'); teal=HexColor('#0E7490'); pale=HexColor('#F4F8FB'); red=HexColor('#A61B1B'); amber=HexColor('#FFF2CC'); green=HexColor('#E2F0D9') styles=getSampleStyleSheet() styles.add(ParagraphStyle(name='Title2',parent=styles['Title'],fontName='Helvetica-Bold',fontSize=21,leading=25,textColor=navy,alignment=TA_CENTER,spaceAfter=6)) styles.add(ParagraphStyle(name='Sub',parent=styles['Normal'],fontName='Helvetica',fontSize=9.2,leading=12,textColor=HexColor('#44546A'),alignment=TA_CENTER,spaceAfter=10)) styles.add(ParagraphStyle(name='H',parent=styles['Heading2'],fontName='Helvetica-Bold',fontSize=12,leading=15,textColor=navy,spaceBefore=8,spaceAfter=5)) styles.add(ParagraphStyle(name='Hsmall',parent=styles['Heading3'],fontName='Helvetica-Bold',fontSize=10,leading=12,textColor=teal,spaceBefore=5,spaceAfter=3)) styles.add(ParagraphStyle(name='Body2',parent=styles['BodyText'],fontName='Helvetica',fontSize=8.1,leading=10.2,spaceAfter=3)) styles.add(ParagraphStyle(name='Tiny',parent=styles['BodyText'],fontName='Helvetica',fontSize=6.8,leading=8.2,spaceAfter=2)) styles.add(ParagraphStyle(name='Call',parent=styles['BodyText'],fontName='Helvetica-Bold',fontSize=8.2,leading=10.5,textColor=red)) def P(t, sty='Body2'): return Paragraph(t,styles[sty]) def table(data,widths,header=True,font=7.1): t=Table(data,colWidths=widths,repeatRows=1 if header else 0,hAlign='LEFT') ts=[('VALIGN',(0,0),(-1,-1),'TOP'),('GRID',(0,0),(-1,-1),0.25,HexColor('#AAB7C4')),('LEFTPADDING',(0,0),(-1,-1),4),('RIGHTPADDING',(0,0),(-1,-1),4),('TOPPADDING',(0,0),(-1,-1),3),('BOTTOMPADDING',(0,0),(-1,-1),3)] if header: ts += [('BACKGROUND',(0,0),(-1,0),navy),('TEXTCOLOR',(0,0),(-1,0),colors.white),('FONTNAME',(0,0),(-1,0),'Helvetica-Bold')] for r in range(1 if header else 0,len(data)): if r%2: ts.append(('BACKGROUND',(0,r),(-1,r),pale)) t.setStyle(TableStyle(ts)); return t class NumberedCanvas(canvas.Canvas): def __init__(self,*args,**kwargs): canvas.Canvas.__init__(self,*args,**kwargs); self.pages=[] def showPage(self): self.pages.append(dict(self.__dict__)); self._startPage() def save(self): n=len(self.pages) for state in self.pages: self.__dict__.update(state); self.setStrokeColor(HexColor('#AAB7C4')); self.line(1.5*cm,1.25*cm,19.5*cm,1.25*cm) self.setFillColor(HexColor('#44546A')); self.setFont('Helvetica',7.2) self.drawString(1.5*cm,.78*cm,'Antidepressants in Anaesthesia | quick-reference | educational use') self.drawRightString(19.5*cm,.78*cm,f'Page {self._pageNumber} of {n}') canvas.Canvas.showPage(self) canvas.Canvas.save(self) doc=SimpleDocTemplate(out,pagesize=A4,rightMargin=1.45*cm,leftMargin=1.45*cm,topMargin=1.25*cm,bottomMargin=1.55*cm) story=[] story += [P('ANTIDEPRESSANTS IN ANAESTHESIA','Title2'),P('Perioperative quick-reference for senior anaesthesia trainees | 23 September 2026','Sub')] story += [Table([[P('<b>Bottom line</b>', 'Body2'),P('Most antidepressants are continued through surgery. Screen for serotonergic co-medication, ECG/QT risk, sodium and bleeding risk. MAOIs require a documented, drug-specific plan with psychiatry and anaesthesia.', 'Body2')]],colWidths=[3.0*cm,15*cm],style=[('BACKGROUND',(0,0),(0,0),amber),('BACKGROUND',(1,0),(1,0),HexColor('#FFF9E6')),('BOX',(0,0),(-1,-1),0.5,HexColor('#D6B656')),('VALIGN',(0,0),(-1,-1),'TOP'),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)]),Spacer(1,5)] story += [P('1. Preoperative checklist','H')] for x in ['Record <b>agent, dose, timing, indication</b> and prescriber. Do not stop abruptly without a plan: withdrawal and relapse may complicate recovery.', 'Ask about additional serotonergic agents: tramadol, meperidine (pethidine), methadone, dextromethorphan, triptans, linezolid, lithium, St John’s wort, cocaine/MDMA. Flag planned <b>methylene blue</b>.', 'Check for: prior serotonin toxicity; seizures; postural hypotension; arrhythmia/QT prolongation; hyponatraemia risk; and concurrent antiplatelet, anticoagulant, or NSAID therapy.', 'For MAOI: establish whether it is irreversible/nonselective (phenelzine, tranylcypromine, isocarboxazid), reversible MAO-A (moclobemide), or selective MAO-B (eg, selegiline/rasagiline). Discuss elective plans early.']: story.append(P('• '+x)) story += [P('2. Class-by-class anaesthetic guide','H')] data=[[P('Class / examples','Tiny'),P('Key effects','Tiny'),P('Perioperative approach and anaesthetic implications','Tiny')], [P('<b>SSRIs</b><br/>sertraline, escitalopram, citalopram, fluoxetine, paroxetine','Tiny'),P('↑ serotonin. Sexual/GI effects; SIADH/hyponatraemia. Platelet serotonin depletion may increase bleeding. Citalopram/escitalopram: QT concern.','Tiny'),P('<b>Usually continue.</b> Avoid stacking serotonergic drugs. Check Na+ in susceptible patients and ECG/QT risks where relevant. Consider bleeding context if combined with NSAID/antiplatelet/anticoagulant therapy. Fluoxetine has a long half-life; stopping immediately before surgery does not remove interaction risk.','Tiny')], [P('<b>SNRIs</b><br/>venlafaxine, duloxetine, desvenlafaxine','Tiny'),P('↑ serotonin + noradrenaline. Nausea, hypertension/tachycardia, withdrawal; possible hyponatraemia/bleeding and serotonergic toxicity.','Tiny'),P('<b>Usually continue.</b> Monitor BP, HR, sodium and QT risk if other factors/drugs coexist. Avoid serotonergic analgesic combinations. Duloxetine may be used for neuropathic pain.','Tiny')], [P('<b>TCAs</b><br/>amitriptyline, nortriptyline, imipramine, clomipramine','Tiny'),P('NE/5-HT reuptake block plus antimuscarinic, antihistaminic and alpha-blocking effects. Sedation, orthostasis, tachycardia, conduction delay/QRS-QT effects, reduced seizure threshold.','Tiny'),P('<b>Usually continue.</b> Obtain ECG when cardiac disease, high dose or symptoms. Anticipate additive anticholinergic/sedative effects and arrhythmia risk. Use vasopressors carefully, titrating direct-acting agents. Avoid excessive sympathetic stimulation.','Tiny')], [P('<b>MAOIs</b><br/>phenelzine, tranylcypromine; moclobemide; selegiline/rasagiline','Tiny'),P('Reduced monoamine metabolism. Potential serotonin toxicity and exaggerated pressor response to indirect sympathomimetics.','Tiny'),P('<b>Individualised decision only.</b> Continuation can be feasible with an MAOI-safe technique, but elective cessation needs psychiatry input and adequate washout if chosen. Avoid meperidine and tramadol; avoid indirect sympathomimetics such as ephedrine. Use direct-acting vasopressors in small titrated doses. Avoid/strongly reconsider methylene blue and linezolid.','Tiny')], [P('<b>Atypicals</b><br/>mirtazapine, bupropion, trazodone, vortioxetine','Tiny'),P('Mirtazapine: sedation/weight gain. Bupropion: noradrenergic-dopaminergic; lowers seizure threshold. Trazodone: sedation, orthostasis, QT risk. Vortioxetine: serotonergic.','Tiny'),P('<b>Usually continue.</b> Consider additive sedation/hypotension with mirtazapine or trazodone. Avoid factors that reduce seizure threshold with bupropion. Treat vortioxetine as serotonergic for interaction screening.','Tiny')]] story.append(table(data,[3.2*cm,5.8*cm,9.0*cm],font=6.8)) story.append(PageBreak()) story += [P('3. Interaction map: practical intraoperative choices','H')] data=[[P('Situation','Tiny'),P('Preferred / acceptable approach','Tiny'),P('Avoid or use only after explicit risk assessment','Tiny')], [P('<b>Analgesia in a serotonergic antidepressant</b>','Tiny'),P('Multimodal non-serotonergic analgesia where suitable; morphine, hydromorphone, oxycodone or fentanyl are commonly used, but observe for toxicity in high-risk polypharmacy.','Tiny'),P('<b>Meperidine and tramadol</b> are the most useful avoid flags. Methadone has serotonergic activity. Use caution with fentanyl-class opioids in patients with multiple serotonergic agents or prior toxicity.','Tiny')], [P('<b>MAOI and hypotension</b>','Tiny'),P('Volume assessment; <b>direct-acting</b> vasopressor (phenylephrine, noradrenaline) in small, titrated doses with close BP monitoring.','Tiny'),P('<b>Ephedrine</b> and other indirect-acting sympathomimetics. Avoid large un-titrated pressor boluses.','Tiny')], [P('<b>Antiemesis / antibiotics / dyes</b>','Tiny'),P('Choose regimen after serotonergic-risk review. Standard agents may still be used case-by-case with monitoring.','Tiny'),P('<b>Methylene blue</b>: potent MAO-A inhibitor and a key perioperative precipitant. <b>Linezolid</b> is also an MAOI. Ondansetron/metoclopramide have been implicated in serotonergic combinations: do not treat them as sole causes, but avoid unnecessary stacking and monitor.','Tiny')], [P('<b>QT / arrhythmia risk</b>','Tiny'),P('Correct K+, Mg2+, Ca2+; ECG monitoring when risk factors coexist; minimise QT-prolonging drug burden.','Tiny'),P('High-risk combinations with citalopram/escitalopram, TCAs or trazodone plus other QT-prolonging agents, bradycardia or electrolyte abnormalities.','Tiny')], [P('<b>Bleeding</b>','Tiny'),P('Continue most SSRI/SNRI therapy. Assess procedure-specific bleeding risk and concurrent NSAID, antiplatelet or anticoagulant exposure.','Tiny'),P('Automatic SSRI/SNRI cessation: benefit is uncertain and withdrawal/relapse may outweigh a small bleeding signal. Make a multidisciplinary decision for very high-bleeding-risk surgery.','Tiny')]] story.append(table(data,[3.35*cm,7.1*cm,7.55*cm])) story += [P('4. Serotonin syndrome: recognise and treat','H')] story.append(Table([[P('<b>Think of it when:</b> serotonergic exposure plus rapid onset of <b>neuromuscular hyperactivity</b> (inducible/spontaneous clonus, hyperreflexia, tremor, rigidity), <b>autonomic activation</b> (hyperthermia, tachycardia, hypertension, diaphoresis, diarrhoea) and <b>mental-status change</b>. Intraoperative diagnosis is difficult. Differential diagnoses include malignant hyperthermia, neuroleptic malignant syndrome, anticholinergic toxicity, sepsis and inadequate anaesthesia.','Body2')]],colWidths=[18*cm],style=[('BACKGROUND',(0,0),(-1,-1),HexColor('#FCE4D6')),('BOX',(0,0),(-1,-1),0.5,HexColor('#C55A11')),('LEFTPADDING',(0,0),(-1,-1),6),('RIGHTPADDING',(0,0),(-1,-1),6),('TOPPADDING',(0,0),(-1,-1),5),('BOTTOMPADDING',(0,0),(-1,-1),5)])) for x in ['Stop suspected serotonergic drugs and call for senior help. Support airway, oxygenation, circulation and temperature control; continuous monitoring and ICU/HDU for moderate-severe cases.', 'Give benzodiazepines for agitation, tremor and seizures. Use active external cooling for hyperthermia. Severe rigidity/hyperthermia may require intubation, paralysis with a <b>non-depolarising</b> neuromuscular blocker and critical care.', 'Cyproheptadine may be considered in moderate-severe toxicity when enteral administration is feasible, following local toxicology/critical-care guidance. Avoid physical restraint where possible.']: story.append(P('• '+x)) story += [P('5. Toxicity pearls: TCA overdose','H'),P('Suspect with anticholinergic features, coma/seizures, hypotension, broad QRS, ventricular dysrhythmia. Immediate priorities are ABCDE, continuous ECG, early toxicology/ICU involvement, benzodiazepines for seizures and <b>IV sodium bicarbonate</b> for QRS widening, ventricular arrhythmia or hypotension attributable to sodium-channel blockade. Avoid class IA/IC antiarrhythmics.','Body2')] story.append(PageBreak()) story += [P('6. Elective-procedure decision aid','H')] data=[[P('Medication group','Tiny'),P('Default','Tiny'),P('When to escalate or modify plan','Tiny')], [P('SSRI / SNRI / TCA / mirtazapine / bupropion / trazodone / vortioxetine','Tiny'),P('<b>Continue on day of surgery</b> in most patients.','Tiny'),P('Prior serotonin toxicity, major QT/conduction disease, severe hyponatraemia, complex antithrombotic regimen, high-bleeding-risk operation, or inability to administer enteral medication postoperatively.','Tiny')], [P('Irreversible nonselective MAOI','Tiny'),P('<b>Do not make an ad hoc stop decision.</b> Continue with MAOI-safe technique or taper/stop only via psychiatry-led plan.','Tiny'),P('Elective operation involving expected need for contraindicated drugs; unclear drug history; inability to ensure avoidance of meperidine/tramadol/indirect sympathomimetics/methylene blue. If stopped, irreversible agents may require approximately 2 weeks for enzyme regeneration, but follow agent-specific specialist advice.','Tiny')], [P('Moclobemide / MAO-B inhibitor','Tiny'),P('Agent- and indication-specific plan.','Tiny'),P('Check current local handbook and psychiatry/neurology advice. Interaction risk is lower in some settings but serotonergic and pressor interactions are not eliminated.','Tiny')]] story.append(table(data,[4.0*cm,6.3*cm,7.7*cm])) story += [P('7. Viva-ready answers','H')] for q,a in [('<b>Why continue SSRIs perioperatively?</b>','To avoid discontinuation syndrome and relapse; instead reduce avoidable serotonergic interaction and bleeding risks.'),('<b>Which opioid is classically contraindicated with MAOIs?</b>','Meperidine (pethidine). Tramadol is also avoided. Use direct-acting vasopressors rather than ephedrine.'),('<b>What is the clinical hallmark of serotonin syndrome?</b>','Clonus and hyperreflexia in an appropriate serotonergic exposure, often with autonomic instability and hyperthermia.'),('<b>What is the immediate anaesthetic response to suspected serotonin toxicity?</b>','Stop triggers, supportive resuscitation, benzodiazepine sedation, active cooling and escalate to critical care/toxicology.')]: story += [P(q,'Hsmall'),P(a)] story += [P('Key cautions','H'),P('This sheet is for revision and point-of-care orientation, not a substitute for institutional medication policies, pharmacist advice, toxicology support, product information or specialist psychiatric input. Drug interaction risk depends on dose, combinations, comorbidity and procedure.','Call')] story += [P('Selected sources','H'),P('Morgan & Mikhail’s Clinical Anesthesiology, 7e, “Depression”, pp. 1165 onward. Barash, Cullen & Stoelting’s Clinical Anesthesia, 9e, “Monoamine Oxidase Inhibitors”. Bartakke A, Corredor C, van Rensburg A. Serotonin syndrome in the perioperative period. BJA Education. 2020;20:10-17. OpenAnesthesia: MAO Inhibitors: Anesthetic Interactions (accessed 23 Sep 2026). World Federation of Societies of Anaesthesiologists, Anaesthesia & Psychiatric Drugs Part 1: Antidepressants (ATOTW 164).','Tiny')] doc.build(story,canvasmaker=NumberedCanvas) print(out) PY

python - <<'PY' from pypdf import PdfReader p='/tmp/workspace/antidepressants-anaesthesia/output/Antidepressants_in_Anaesthesia_Quick_Reference.pdf' r=PdfReader(p) print('exists',len(r.pages),'pages', 'size',__import__('os').path.getsize(p)) for i,page in enumerate(r.pages,1): tx=page.extract_text() or '' print(i, len(tx), tx[:80].replace('\n',' | ')) PY

~/antidepressants-anaesthesia/output

mkdir -p "/tmp/workspace/antidepressants-anaesthesia/output" && python -c "from reportlab.pdfgen import canvas; from reportlab.lib.pagesizes import A4; p='/tmp/workspace/antidepressants-anaesthesia/output/Antidepressants_in_Anaesthesia_Quick_Reference.pdf'; c=canvas.Canvas(p,pagesize=A4); c.setFont('Helvetica-Bold',22); c.drawString(72,770,'ANTIDEPRESSANTS IN ANAESTHESIA'); c.setFont('Helvetica',10); c.drawString(72,748,'Perioperative quick-reference for senior anaesthesia trainees'); c.setFont('Helvetica-Bold',14); c.drawString(72,710,'1. Perioperative principles'); c.setFont('Helvetica',10); lines=['Most antidepressants are continued through surgery. Do not stop abruptly without a documented plan.','Screen for serotonergic co-medication, ECG/QT risk, hyponatraemia, bleeding risk and MAOI use.','For MAOIs, agree an agent-specific plan with anaesthesia, psychiatry and pharmacy before elective surgery.','','2. Class guide','SSRIs/SNRIs: Usually continue. Watch for serotonin toxicity, SIADH/hyponatraemia, bleeding with NSAIDs/antiplatelets/anticoagulants, and QT risk.','TCAs: Usually continue. Anticholinergic effects, orthostasis, sedation, conduction delay/arrhythmia and reduced seizure threshold. Consider ECG.','MAOIs: Individualised. Avoid meperidine, tramadol, methylene blue, linezolid and indirect sympathomimetics such as ephedrine. Titrate direct-acting vasopressors.','Atypicals: Usually continue. Mirtazapine/trazodone cause sedation and orthostasis; bupropion lowers seizure threshold; vortioxetine is serotonergic.','','3. Serotonin syndrome','Think: serotonergic exposure plus clonus/hyperreflexia, agitation, diaphoresis, hyperthermia, tachycardia or labile BP.','Stop triggers, support airway/circulation, give benzodiazepines, active cooling, escalate to ICU/toxicology.','Differentiate from malignant hyperthermia, neuroleptic malignant syndrome, sepsis and anticholinergic toxicity.','','4. TCA overdose','ABCDE, ECG, toxicology/ICU; benzodiazepines for seizures. Use IV sodium bicarbonate for QRS widening, ventricular arrhythmia or hypotension due to sodium-channel blockade.','','Viva pearl: Meperidine is classically contraindicated with MAOIs; tramadol should also be avoided.']; y=690; c.setFont('Helvetica',9.3); [ (c.drawString(78,y-13*i,line)) for i,line in enumerate(lines) ]; c.setFont('Helvetica-Oblique',7.5); c.drawString(72,55,'Educational reference only. Follow institutional guidance and specialist advice.'); c.showPage(); c.save(); print(p)"

~/antidepressants-anaesthesia/build_pdf.py

python "/tmp/workspace/antidepressants-anaesthesia/build_pdf.py"

"serotonin syndrome" AND perioperative

serotonin syndrome emergency management cyproheptadine benzodiazepines critical care guideline

~/

mkdir -p "/tmp/workspace/serotonin-syndrome-emergency-card/output" && python - <<'PY' from reportlab.pdfgen import canvas from reportlab.lib.pagesizes import A4 from reportlab.lib.colors import HexColor, white, black from reportlab.lib.units import cm from reportlab.pdfbase.pdfmetrics import stringWidth from pypdf import PdfReader import os out='/tmp/workspace/serotonin-syndrome-emergency-card/output/Serotonin_Syndrome_Emergency_Card.pdf' W,H=A4 c=canvas.Canvas(out,pagesize=A4) # palette navy=HexColor('#12263F'); red=HexColor('#B42318'); orange=HexColor('#D05A00'); pale_red=HexColor('#FDE8E7'); pale_orange=HexColor('#FFF1E6'); pale_blue=HexColor('#EEF5FA'); line=HexColor('#A7B5C2'); text=HexColor('#18212B'); green=HexColor('#1D6A45') # helpers def rect(x,y,w,h,fill,stroke=None,sw=.6): c.setFillColor(fill); c.setStrokeColor(stroke or fill); c.setLineWidth(sw); c.rect(x,y,w,h,fill=1,stroke=1 if stroke else 0) def wrap(s,font,size,width): words=s.split(); rows=[]; cur='' for wd in words: t=(cur+' '+wd).strip() if stringWidth(t,font,size)<=width: cur=t else: if cur: rows.append(cur) cur=wd if cur: rows.append(cur) return rows def para(x,y,s,width,size=8.6,leading=10.5,font='Helvetica',color=text,bullet=False): c.setFont(font,size); c.setFillColor(color) for line0 in wrap(s,font,size,width-(10 if bullet else 0)): if bullet: c.drawString(x,y,u'•'); c.drawString(x+9,y,line0) else: c.drawString(x,y,line0) y-=leading return y def title(x,y,s,size=11,color=navy): c.setFillColor(color); c.setFont('Helvetica-Bold',size); c.drawString(x,y,s) # header rect(0,H-3.35*cm,W,3.35*cm,navy) c.setFillColor(white); c.setFont('Helvetica-Bold',23); c.drawString(1.3*cm,H-1.45*cm,'SEROTONIN SYNDROME') c.setFont('Helvetica-Bold',11); c.drawString(1.3*cm,H-2.05*cm,'EMERGENCY RECOGNITION & INITIAL MANAGEMENT CARD') c.setFont('Helvetica',7.4); c.drawString(1.3*cm,H-2.62*cm,'For trained clinicians. Stop triggers, resuscitate, monitor and escalate early.') left=1.3*cm; gap=.45*cm; col=(W-2*left-gap)/2; right=left+col+gap; y=H-3.75*cm # diagnosis strip rect(left,y-1.36*cm,W-2*left,1.26*cm,pale_red,red,.8) title(left+.25*cm,y-.42*cm,'SUSPECT IT',10.5,red) para(left+3.0*cm,y-.38*cm,'Recent serotonergic drug exposure + rapid onset (usually hours) of neuromuscular hyperactivity, autonomic excitation and altered mental state.',W-2*left-3.3*cm,8.2,10,'Helvetica-Bold') y-=1.7*cm # left card clinical rect(left,y-4.5*cm,col,4.4*cm,pale_blue,line,.6) title(left+.22*cm,y-.42*cm,'1. RECOGNISE: HUNTER-STYLE CLUES',10,navy) yl=y-.8*cm for s in [ '<b>CLONUS is the key sign:</b> spontaneous clonus; or inducible/ocular clonus with agitation, diaphoresis or fever.', 'Tremor + hyperreflexia, especially lower limbs.', 'Autonomic: tachycardia, hypertension, diaphoresis, diarrhoea, mydriasis, hyperthermia.', 'Mental state: agitation, anxiety, confusion. Severe: rigidity, seizures, coma.' ]: # Rich not supported simpler bold substitute yl=para(left+.25*cm,yl,s.replace('<b>','').replace('</b>',''),col-.48*cm,8.1,10,'Helvetica',text,True)-3 c.setFillColor(red); c.setFont('Helvetica-Bold',8.2); c.drawString(left+.25*cm,y-4.1*cm,'Hyperthermia is a late, ominous sign. Absence does NOT exclude it.') # right red flags rect(right,y-4.5*cm,col,4.4*cm,pale_orange,HexColor('#E09841'),.6) title(right+.22*cm,y-.42*cm,'2. FIRST 5 MINUTES',10,orange) yr=y-.83*cm for s in [ 'STOP all serotonergic agents and remove/avoid the suspected trigger.', 'CALL senior anaesthetist + ICU. Contact toxicology/poisons service early.', 'ABCDE: high-flow oxygen, IV access, continuous ECG, BP, SpO2 and core temperature monitoring.', 'Check glucose; obtain ABG/VBG, electrolytes, CK, renal function and coagulation as clinically indicated.', 'Do NOT delay resuscitation waiting for tests: diagnosis is clinical.' ]: yr=para(right+.25*cm,yr,s,col-.48*cm,8.1,10,'Helvetica',text,True)-3 y-=4.85*cm # full action box rect(left,y-5.65*cm,W-2*left,5.55*cm,white,line,.7) title(left+.22*cm,y-.43*cm,'3. TREAT BY SEVERITY',10.5,navy) # split 3 mini columns inner= W-2*left-.44*cm; cw=(inner-.3*cm)/3 xs=[left+.22*cm,left+.22*cm+cw+.15*cm,left+.22*cm+2*(cw+.15*cm)] heads=[('MILD',green),('MODERATE',orange),('SEVERE / LIFE-THREATENING',red)] contents=[ ['Stop agents and observe closely.','IV fluids as needed.','Benzodiazepine for agitation/tremor.','Most improve within 24-72 h after trigger removal.'], ['Admit for monitored care.','Benzodiazepines, IV fluids, external cooling.','Treat BP/HR abnormalities with short-acting, titratable agents.','Consider cyproheptadine after senior/toxicology advice.'], ['ICU now. Intubate and ventilate if severe hyperthermia, rigidity or deteriorating consciousness.','Deep sedation and NON-depolarising paralysis if needed.','Aggressive external cooling.','Treat complications: rhabdomyolysis, acidosis, renal injury, dysrhythmia.']] for x,(hd,colr),items in zip(xs,heads,contents): rect(x,y-1.02*cm,cw,.54*cm,colr) c.setFillColor(white); c.setFont('Helvetica-Bold',8); c.drawCentredString(x+cw/2,y-.82*cm,hd) yy=y-1.32*cm for it in items: yy=para(x,yy,it,cw,7.65,9.2,'Helvetica',text,True)-2 # cypro panel cy=y-5.05*cm rect(left+.22*cm,cy,W-2*left-.44*cm,.76*cm,pale_orange,HexColor('#E09841'),.5) title(left+.4*cm,cy+.48*cm,'CYPROHEPTADINE (enteral only)',8.7,orange) para(left+5.0*cm,cy+.47*cm,'Consider if supportive care + benzodiazepines are insufficient. Adult reference regimen: 12 mg PO/NG, then 2 mg every 2 h until response. Follow local toxicology protocol.',W-2*left-5.45*cm,7.5,9,'Helvetica') y-=6.05*cm # triggers/differentials rect(left,y-4.35*cm,col,4.25*cm,HexColor('#F8FAFC'),line,.6) title(left+.22*cm,y-.42*cm,'4. HIGH-YIELD TRIGGERS',10,navy) yl=y-.78*cm for s in ['Antidepressants: SSRI/SNRI, TCA, MAOI, trazodone, vortioxetine.','Perioperative: meperidine (pethidine), tramadol, methadone, fentanyl-class opioids in susceptible polypharmacy, ondansetron/metoclopramide as contributors.','MAOI activity: methylene blue, linezolid.','Other: dextromethorphan, triptans, lithium, St John’s wort, MDMA/cocaine.']: yl=para(left+.25*cm,yl,s,col-.48*cm,7.75,9.3,'Helvetica',text,True)-2 rect(right,y-4.35*cm,col,4.25*cm,HexColor('#F8FAFC'),line,.6) title(right+.22*cm,y-.42*cm,'5. DIFFERENTIALS: FAST DISCRIMINATORS',10,navy) yr=y-.78*cm for s in ['Malignant hyperthermia: triggering anaesthetic exposure, hypercapnia/rigidity, metabolic acidosis; clonus/hyperreflexia are not typical.','Neuroleptic malignant syndrome: dopamine antagonist/withdrawal exposure, slower onset over days, lead-pipe rigidity and bradyreflexia.','Anticholinergic toxicity: dry skin/mucosa, urinary retention, absent bowel sounds rather than clonus/diarrhoea.','Sepsis, thyroid storm, withdrawal, heat stroke and inadequate anaesthesia may mimic features.']: yr=para(right+.25*cm,yr,s,col-.48*cm,7.6,9.1,'Helvetica',text,True)-2 # footer c.setStrokeColor(line); c.line(left,1.43*cm,W-left,1.43*cm) c.setFillColor(HexColor('#44546A')); c.setFont('Helvetica',6.65) c.drawString(left,1.1*cm,'Educational emergency aid. Follow local protocol, medicines information and toxicology advice. Updated 23 Sep 2026.') c.drawRightString(W-left,1.1*cm,'Sources: Tintinalli’s Emergency Medicine; Washington Manual; BJA Education 2020.') c.save() r=PdfReader(out) text=''.join((page.extract_text() or '') for page in r.pages) assert len(r.pages)==1, f'Expected 1 page, got {len(r.pages)}' assert 'SEROTONIN SYNDROME' in text and os.path.getsize(out)>10000 print(out, len(r.pages), os.path.getsize(out)) PY

~/serotonin-syndrome-emergency-card/output

python - <<'PY' from pypdf import PdfReader import os p='/tmp/workspace/serotonin-syndrome-emergency-card/output/Serotonin_Syndrome_Emergency_Card.pdf' r=PdfReader(p) t=''.join(page.extract_text() or '' for page in r.pages) print('pages=',len(r.pages),'bytes=',os.path.getsize(p),'textchars=',len(t)) print(t[:1000]) PY