Critical Care: Student/Resident Case Report Poster - Critical Care V |

Serotonin Syndrome Caused by Fentanyl Without Other Serotonergic Agents FREE TO VIEW

Bertin Salguero, BS; Gizelle Stevens, MBBS; Paul Kinniry, MD
Author and Funding Information

Universidad Francisco Marroquin, Guatemala City, Guatemala

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):460A. doi:10.1016/j.chest.2016.08.473
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Critical Care V

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Serotonin syndrome (SS) is characterized by hyperactive delirium, neuromuscular irritability and autonomic instability by overdosage or by interaction of multiple serotonergic agents. This is the first published case where SS is developed with a single serotonergic agent.

CASE PRESENTATION: 66 year old female presented with a month history of dyspnea, found to have COPD exacerbation and NSTEMI requiring intubation for respiratory failure. She received Propofol initially but was switched to Fentanyl for sedation due to reduced EF. Since admission, she presented with hyperactive delirium with asynchrony during ventilation requiring higher amounts of Lorazepam and Fentanyl. Lorazepam was discontinued for management as ICU delirium. Dexmedetomidine (DEX) and Haloperidol were started. After 24 hours she exhibited episodes of increased agitation with multiple paroxysmal spikes of Systolic Blood Pressure (SBP) from 130mmHg to 360mmHg. She had inducible clonus in her lower extremities not present on admission. Ocular clonus and hyperthermia were absent. She was tachycardic with ventricular bigeminy. She was diagnosed with SS, which included exposure to a serotonergic agent, hyperactive delirium, autonomic instability and inducible myoclonus. Serum CPK, Lactate and Head CT were normal. She was treated with Cyprohepatadine along with IV Lorazepam and Nicardipine. After the first 24 hours of treatment, the inducible clonus was no longer elicited and her paroxysmal increases of SBP and agitation significantly decreased.

DISCUSSION: There are no published cases of SS in a patient taking a standard dose of Fentanyl without an added serotonergic agent nor with worsening of the clinical status after IV Haloperidol. The disappearance of the myoclonus and the reduction in the autonomic instability showed an adequate response to treatment. There is only one published case series where DEX is used for treatment of SS. In it, 3 adolescents with SS that required intubation unresponsive to Midazolam and/or Propofol, DEX was used showing autonomic stabilization and improvement of the agitation (2). In our case, after achieving a stable dose of DEX, she developed worsening autonomic instability without changes to the delirium. It is not certain if our patient would have shown improvement if it was continued for more than 24 hours, but the cardiac manifestation after its administration were evident.

CONCLUSIONS: This case shows a representative patient with SS caused by administration of a single serotoninergic agent in combination with Haloperidol and DEX. It shows how SS can be developed without the need to have multiple serotoninergic agents in the same patient.

Reference #1: Pedavally S,Fugate JE,Rabinstein AA. Serotonin syndrome in the intensive care unit: clinical presentations and precipitating medications.NeurocriticalCare. 2014 Aug;21(1):108-13

Reference #2: Rushton WF,Charlton NP. Dexmedetomidine in the Treatment of Serotonin Syndrome. Annals of Pharmacotherapy. 2014;48(12):1651-1654

DISCLOSURE: The following authors have nothing to disclose: Bertin Salguero, Gizelle Stevens, Paul Kinniry

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543