Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

SerSyndrome

5,243 views

Published on

Published in: Education, Health & Medicine
  • This is very helpful thanks a lot
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

SerSyndrome

  1. 1. Serotonin Syndrome Gabriel Tsao, MS3 Ben Berk, MS4 Gabriel Tsao, MS3 Stanford University School of Medicine Left Brain vs Right Brain
  2. 2. Case <ul><li>ID/CC: 45 yo w/ h/o bipolar disorder s/p sigmoid colectomy for adeno CA. </li></ul><ul><li>Prior outpatient meds: Lexapro 10, Seroquel 800 qhs, Keppra 500/1000, Xanax >4mg qd, Ambien 10 qhs </li></ul><ul><li>Hospital course: acutely psychotic post-op </li></ul><ul><li>Max Inpatient Meds: Lexapro 10, Seroquel 800 qhs, Keppra 500 q8, Valproic Acid 750/1000, Versed gtt 6, clonidine patch, Ativan 3/3/3/5, Fentanyl gtt 200, Haldol 4/4/4/10, donepazil 10, zofran 8, and olanzapine 5mg q8h PRN </li></ul>
  3. 3. Physical exam <ul><li>Hyperthermia ~40º, tremor, agitation, diarrhea, diaphoretic, HTN </li></ul><ul><li>Psych recommended discontinuing all psychiatric medications, only on valium and fentanyl. </li></ul><ul><li>Within 48 hrs, pt dramatically recovered </li></ul>
  4. 4. Serotonin Syndrome <ul><li>Libby Zion (1984) </li></ul><ul><ul><li>An 18 yo college student who presented to the hospital with a fever of 103.5, agitation, confusion, “jerking motions.” </li></ul></ul><ul><ul><li>Had been taking an antidepressent, phenelzine. </li></ul></ul><ul><ul><li>Given meperidine in the hospital </li></ul></ul><ul><ul><li>Increasingly agitated, restrained </li></ul></ul><ul><ul><li>Six hours later, temp 107, cardiac arrest </li></ul></ul>
  5. 5. Public Outrage <ul><li>Ms. Zion was seen only be an intern and R2 </li></ul><ul><ul><li>The R2 had 40+ other patients to cover </li></ul></ul><ul><ul><li>36 hour shift </li></ul></ul><ul><li>Father was a writer for NY Times </li></ul><ul><ul><li>Story featured in NY Times, Newsweek, Washington Post, 60 Minutes </li></ul></ul><ul><li>1986 DA convened Grand Jury </li></ul><ul><li>1989 NY State adopted 80 hr resident work week restriction w/ supervision guidelines </li></ul><ul><li>2003 ACGME adopts similar standards </li></ul>
  6. 6. Incidence of Serotonin Syndrome <ul><li>Observed in all age groups </li></ul><ul><li>Increasing incidence thought to be associated with increased use of serotonergic agents </li></ul><ul><li>2004: Toxic Exposure Surveillance System </li></ul><ul><ul><li>48,204 exposures to SSRIs that resulted in moderate or major outcomes in 8187 pts and 103 deaths. </li></ul></ul><ul><li>Occurs in 14-16% of persons who overdose SSRIs </li></ul><ul><li>Incidence difficult to assess </li></ul><ul><ul><li>85% of physicians in 1999 were unaware of serotonin syndrome as a clinical diagnosis </li></ul></ul>Mackay FJ, et al. Antidepressants and the serotonin syndrome in general practice. Br J Gen Pract 1999; 49:871-9.
  7. 7. Serotonin <ul><li>In the CNS </li></ul><ul><ul><li>Modulates attention, behavior and thermoregulation </li></ul></ul><ul><li>In the Periphery </li></ul><ul><ul><li>Vascular tone and gastric motility </li></ul></ul>
  8. 8. Serotonin Syndrome <ul><li>Stimulation of postsynaptic 5HT1A and 5HT1B receptors implicated </li></ul><ul><ul><li>No one receptor solely responsible </li></ul></ul><ul><li>Any combination of drugs that has net effect increased serotonin neurotransmission </li></ul><ul><ul><li>Classically two simultaneously, but can be with initiation of a single drug or increasing dose in a sensitive individual </li></ul></ul><ul><li>Seen in intentional overdoses </li></ul>
  9. 9. Features of Serotonin Syndrome <ul><li>Classic clinical triad: </li></ul><ul><ul><li>Mental status changes </li></ul></ul><ul><ul><li>Autonomic hyperactivity </li></ul></ul><ul><ul><li>Neuromuscular abnormalities </li></ul></ul><ul><li>Wide ranging symptoms </li></ul>
  10. 11. Diagnosis <ul><li>Hunter Criteria: (84% sensitive, 97% specific) </li></ul><ul><ul><li>Must have taken a serotonergic agent </li></ul></ul><ul><ul><li>Plus one of following </li></ul></ul><ul><ul><ul><li>Spontaneous clonus </li></ul></ul></ul><ul><ul><ul><li>Inducible clonus plus agitation or diaphoresis </li></ul></ul></ul><ul><ul><ul><li>Ocular clonus plus agitation or diaphoresis </li></ul></ul></ul><ul><ul><ul><li>Tremor and hyper-reflexia </li></ul></ul></ul><ul><ul><ul><li>Hypertonia </li></ul></ul></ul><ul><ul><ul><li>Temperature above 38 plus ocular or inducible clonus </li></ul></ul></ul>
  11. 13. Serotonin Syndrome vs NMS <ul><li>Development </li></ul><ul><ul><li>SS develops over 24 hrs, often 6 hrs </li></ul></ul><ul><ul><li>NMS develops over days to weeks </li></ul></ul><ul><li>Neuromuscular responses </li></ul><ul><ul><li>SS characterized by hyperreactivity </li></ul></ul><ul><ul><ul><li>Tremor, hyperreflexia, myoclonus </li></ul></ul></ul><ul><ul><li>NMS involves sluggish responses </li></ul></ul><ul><ul><ul><li>Rigidity, bradyreflexia </li></ul></ul></ul><ul><li>Resolution </li></ul><ul><ul><li>SS usually resolves within 24 hrs </li></ul></ul><ul><ul><li>NMS requires an average of 9 days </li></ul></ul>
  12. 14. Associated Drugs <ul><li>MR meds </li></ul>
  13. 16. Management <ul><li>Removal of precipitating drugs </li></ul><ul><ul><li>Most cases typically resolve within 24 hrs of removal </li></ul></ul><ul><li>Administration of 5HT antagonists </li></ul><ul><ul><li>Cyproheptadine: 12 mg initial dose, 2 mg q1h </li></ul></ul><ul><li>Control of agitation </li></ul><ul><ul><li>Benzodiazepines regardless of symptom severity </li></ul></ul><ul><ul><li>Physical restraints alone ill-advised (lactic acidosis, temp) </li></ul></ul><ul><li>Control of hyperthermia (>41.1) </li></ul><ul><ul><li>Sedation, neuromuscular paralysis, orotracheal intubation </li></ul></ul><ul><li>Control of autonomic instability </li></ul>
  14. 17. Pitfalls <ul><li>Misdiagnosis of serotonin syndrome </li></ul><ul><ul><li>Failure to comprehend rapidity of progression </li></ul></ul><ul><ul><li>Failure to comprehend adverse pharm effects </li></ul></ul><ul><ul><li>Muscle rigidity can mask clonus and hyperreflexia </li></ul></ul><ul><li>If serotonin syndrome not obvious: </li></ul><ul><ul><li>Withhold 5HT antagonist therapy </li></ul></ul><ul><ul><li>Provide all other therapy </li></ul></ul><ul><ul><li>Anticipate need for aggressive therapy </li></ul></ul>
  15. 18. Thanks <ul><li>Dr. Purtill </li></ul><ul><li>Dr. Spain </li></ul><ul><li>Dr. Patterson </li></ul><ul><li>Team </li></ul><ul><ul><li>Dr. Garland, Amy, Sarah, Geoff and Geoff, Ron, Rich, Rebecca, Ngoc, Ben </li></ul></ul><ul><li>Our twins in the ICU </li></ul>

×