Thomas Jefferson University Class of 2016 Objectives Identify symptoms of serotonin syndrome Identify medications at risk to cause syndrome development Identify possible differential diagnoses Discuss appropriate syndrome treatment ID: 1030420
Download Presentation The PPT/PDF document "Serotonin Syndrome Sarah Laubach, BSN, S..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Serotonin SyndromeSarah Laubach, BSN, SRNAThomas Jefferson UniversityClass of 2016
2. ObjectivesIdentify symptoms of serotonin syndromeIdentify medications at risk to cause syndrome developmentIdentify possible differential diagnosesDiscuss appropriate syndrome treatmentReview case study
3. Serotonin in the Body5-hydroxytryptamine (5-HT)Monoamine neurotransmitter90% of total serotonin in the GI tractRegulates enteric neurons and GI motility10% synthesized in serotonergic CNS neuronsRegulates attention, behavior, thermoregulation
4. Serotonin Syndrome:What is it?A rare, but potentially fatal adverse drug reactionCaused by increased serotonergic activity in the CNSCharacterized by a symptom triad:Altered mental statusNeuromuscular hyperactivityAutonomic instability or hyperactivityPotential for rapid onset and progression
5. Serotonin Syndrome:What is it?Can be caused by certain drugs, interactions between drugs, or intentional overdoseSymptoms range from mild to severeCan be fatal if left untreatedTerms used interchangeablyToxicity: more accurate term, as it “reflects the broad spectrum of serotonin-related side effects progressing to toxicity.”Syndrome: used more commonly in the literature
6. Incidence2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data47,115 people reported toxicity related to SSRIs1723 moderate adverse events152 major adverse events7 deathsAffects all age groups from newborns to older adults
7. IncidenceNumbers most likely underestimatedMay be confused with other medical conditions, especially if symptoms are mildIncidence likely to increase in the future
8. Serotonin Syndrome: CauseDrugs with serotonergic activitySSRIs are most commonly implicatedIncreased extracellular serotonin levels by limiting reabsorption into the presynaptic cellIncreased serotonin in the synaptic cleft, available to bind to the postsynaptic receptor
9. Signs & SymptomsManifests many different waysMental status changesautonomic hyperactivityneuromuscular abnormalitiesmay be accompanied by rigidity, especially in the lower extremitiesMild symptom presentations can rapidly progress to more severe symptomsImportant to pay close attention to warning signs of suspected serotonin syndrome
10. Mild SymptomsAkathisiaAnxietyDiaphoresisHyperreflexiaMild hypertensionTachycardiaMydriasisMyoclonusShiveringTremor
11. Moderate SymptomsAgitationHypervigilanceIncreased ConfusionMyoclonusOcular clonusPressured SpeechTemperature of at least 40 degrees Celsius
12. What is Problematic?
13. Severe SymptomsDramatic swings in pulse rate and blood pressureSeizuresMetabolic AcidosisMuscle rigidityRhabdomyolysisARDSRenal failureRespiratory failureComaDisseminated Intravascular CoagulationShock
14. Symptom ID Made Easy
15. Symptom OnsetCan be rapidSymptoms can occur within minutes of drug administration, a dosage change or overdoseApproximately 60% of reported cases present within six hours of drug therapy
16. TreatmentCease administration of serotonergic medicationAfter cessation of the serotonergic drugs, symptoms usually end within 24 hoursSevere cases can take several days for recoveryShould the case be cancelled? Can it end quickly?Primarily supportive treatment based on symptomsIdentify extent of symptom development through diagnostic testing such as labs and physical assessment
17. Associated DrugsSSRIsOpioid analgesicsHerbal productsSerotonin-releasing agents
18. SSRIsSelective serotonin reuptake inhibitorsFluoxetineFluvoxamineParoxetineCitalopramSertralineEscitalopram
19. Other antidepressantsSelective Norepinephrine Reuptake Inhibitors (SNRIs)VenlafaxineTricyclic Antidepressants (TCAs)ClomipramineImipramineMonoamine Oxidase InhibitorsPhenelzineTranylcypromine
20. Serotonin-releasing AgentsFenfluramineAmphetaminesMethylenedioxymethamphetamineMDMAEcstasy
21. MiscellaneousLithiumTryptophanLinezolidSt. John’s Wort
22. Opioid analgesicsFentanylTramadolPethidineDextreomethorphan
23. Fentanyl & SSRI InteractionBarash, 2011, states serotonin syndrome may be caused by an interaction between fentanyl and SSRIsExact mechanisms through which this reaction occurs are not fully understoodFentanyl is commonly used analgesic in many anesthetic techniques
24. Fentanyl & SSRI InteractionPhenylpiperidine opioids seem to be weak SSRIsMay also enhance serotonin releaseTypes include:FentanylRemifentanilSufentanilAlfentanilTramadolMeperidine
25. Symptom DiagnosisNo laboratory tests available for diagnosisLab and diagnostic testing used to rule out other alternative explanations for the observed signs and symptomsMay initially resemble other conditionsExamination of specific neurological symptoms and ruling out other conditions will aid in making the differential diagnosis
26. Differential DiagnosisWhat conditions can you think of that may resemble the symptoms of Serotonin Syndrome?
27. Differential DiagnosisMalignant HyperthermiaNeuroleptic Malignant SyndromeSevere sepsisMeningoencephalitisDelirium tremensHeat strokeAnticholinergic toxicity
28. Differential Diagnosis: Neuroleptic Malignant SyndromeBradykinesia results in a state of immobilization, akinesia, stupor, fever and autonomic instabilitySerotonin toxicity caused by serotonergic drugs frequently and predictably, also is dose relatedNMS occurs with neuroleptics, but rarely and idiosyncratically, and is NOT dose relatedSS rapid onset and progression over hoursNMS has slow onset and progression over daysSS: hyperkinesia, hyperreflexia/clonus, pyramidal rigidityNMS: bradykinesia and extrapyramidal rigidity
29. Differential Diagnosis:Anticholinergic DeliriumBoth AD and SS manifest with impaired consciousness, tachycardia and pyrexiaSS: Diaphoresis, clonus and hyperreflexia presentAD: Dry skin and mucous membranes without increased tone or hyperreflexia
30. Diagnosis CriteriaTwo main diagnostic criteria to establish serotonin syndromeSternbach’s CriteriaHunter Serotonin Toxicity Criteria
31. Diagnosis: Hunter Serotonin Toxicity CriteriaDeveloped more recentlyConsists of simple but accurate decision rulesEmphasis on clonus as the most important featureStatistically more sensitive (84% vs. 75%) and more specific (97% vs. 96%) than Sternbach’s criteriaConsidered to be the preferred diagnostic tool
32.
33. Current ResearchOctober 2014 AANA practice update states research primarily based on case studiesCan be prone to research bias and limited generalizabilityCase studies described suggests that pts taking SSRIs are at an increased risk for serotonin syndrome following fentanyl administrationMost of the patients reviewed developed severe symptoms and required emergency care
34. The Case of Libby Zion18yoF college student, 1984Prescribed Phenelzine (MAOI) for depressionExperienced worsening “flu-like” symptoms, febrilePresented to ED at 1130 pm
35. The Case of Libby ZionInitial Assessment: writhing and agitated, but able to convey historyFebrile to 103.5o FNormal chest xrayElevated WBC 18,000/mm3Admitted to hospital’s medical serviceEvaluation by intern and resident, with diagnosis of “viral syndrome with hysterial symptoms”Additional cultures ordered, prescribed IM meperidine for agitation and shivering
36. The Case of Libby ZionOver next hour, agitation increasedBecame “confused”, began thrashing around in bedPhysical restraints and haloperidol 1mg orderedPt calmed briefly, agitation returned shortly thereafterTemperature increased to 107o FCooling measures initiated0630am Respiratory/Cardiac arrest
37. Libby Zion LawED physicians did not properly diagnose serotonin syndromeLed to discussions on physician supervision and long work hours for residentsLibby Zion Law, 1989NY State Department of Health Code, Section 405Regulation limits amount of resident physicians’ work in NY state hospitals to 80 hours/weekJuly 2003, the Accreditation Council for Graduate Medical Education adopted similar regulations for all accredited medical training institutions in the US
38. Moving ForwardFentanyl will continue to be a staple of anesthetic managementGoal is to keep serotonin syndrome in mind as a possible differential diagnosis during intraoperative eventsRemember Symptom Triad:Neuromuscular hyperactivityAutonomic hyperactivityAltered mental statusEarly identification is key!
39. Thank you for your timeand attention!
40. ReferencesBarash, P. G. (2013). Clinical anesthesia. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.Davis, J., Buck, N., Swenson, J., Johnson, K., & Greis, P. (2013). Serotonin syndrome manifesting as patient movement during total intravenous anesthesia with propofol and remifentanil. Journal of Clinical Anesthesia, 25, 52-54.Gillman, P. K. (2005). Monoamine oxidase inhibitors, opioid analgesics and serotonin toxicity. British Journal of Anesthesia, 95(4), 434-441. doi:10.1093/bja/aei210Greenier, E., MPH, MBA, Lukyanova, V., PhD, & Reede, L., CRNA, DNP, MBA. (2014). Serotonin syndrome: Fentanyl and selective serotonin reuptake inhibitor interactions AANA Journal, 82(5), 340-345.Stanford, S., Stanford, B., & Gillman, P. (2009). Risk of severe serotonin toxicity following co-administration of methylene blue and serotonin reuptake inhibitors: An update on a case report of post-operative delirium. Journal of Psychopharmacology, , 1-6. doi: 10.1177/0269881109105450Swadron, S. (2011). Serotonin syndrome and the libby zion affair. Retrieved from http://epmonthly.com/article/serotonin-syndrome-and-the-libby-zion-affair/