Perioperative Diagnosis and Treatment of Serotonin Syndrome Following Administration of Methylene Blue

Abstract

Patient: Male, 67Final Diagnosis: Serotonin syndromeSymptoms: Agitation • muscular spasticity, deficient muscular control • nystygmus • sweating • tachycardiaMedication: Methylene BlueClinical Procedure: Total abdominal colectomySpecialty: AnesthesiologyObjective:Unusual clinical courseBackground:Serotonin syndrome (SS) involves serotonergic hyperactivity caused by excessive activation of 5-HT2A receptors. As the use of antidepressants increases, so does the population of patients at risk for developing this complication. The diagnosis is made based on current serotonergic medication use in conjunction with certain clinical signs. The severity of the clinical presentation may vary, especially when the complication occurs while the patient is under general anesthesia. As a result, the incidence of SS is likely underreported and treatment may be delayed, leading to life-threatening complications.Case Report:A 67-year-old, American Society of Anesthesiologist physical status 3 male with multiple medical comorbidities, including anxiety/depression and chronic neck pain, presented for an elective laparoscopic total abdominal colectomy for colonic inertia. His intraoperative course was significant for SS likely triggered by the administration of methylene blue, which only became clinically apparent during anesthetic emergence. We considered and systematically ruled out other potential causes of his clinical condition. His management was primarily supportive, using hydration and benzodiazepine administration, and resulted in full neurologic recovery.Conclusions:SS is an underdiagnosed condition with limited treatment options beyond symptom management. Thus, vigilance, early diagnosis, and cessation of offending medications are of utmost importance. Anesthesiologists managing at-risk surgical patients must have a high clinical suspicion of perioperative SS if their patients exhibit tachycardia, hypertension, and hyperthermia together with clonus, agitation, diaphoresis, or hypertonia. These signs may be masked by general anesthesia and may only manifest themselves upon anesthetic emergence.

The Serotonin Syndrome: From Molecular Mechanisms to Clinical Practice

“…Seventy percent of patients recover completely within 24 h, 40% of patients require admission to an intensive care unit, and only 25% of patients require endotracheal intubation [91]. In addition to stopping serotonergic medications, the treatment of SS in humans has consisted primarily of supportive care, including the administration of benzodiazepines [1,10,92,93,94]. Given that life-threatening manifestations of SS such as rigidity and hyperthermia seem to result only from stimulation of 5-HT 2A receptors [20], it would follow that directed therapy for this disease would target this particular receptor.…”

Serotonin Syndrome Following Methylene Blue Administration for Vasoplegic Syndrome in Heart and Lung Transplantation – A Case Series

“…However, this condition may be precipitated by adding a single dose of MB. The Food and Drug Administration (FDA) recommends for patients who are at risk to be exposed to MB to stop taking serotonergic agents at least 2 weeks prior to its potential administration [25,26].…”

Optimizing the Methylene Blue Removal from Aqueous Solution Using Pomelo Peel Based Biochar Assisted by RSM and ANN-PSO

“…Although MB has an excellent curative effect in the treatment of methemoglobin, it may lead to Heinz body anemia, morphological changes of red blood cells and necrotic edema if the dosage of methylene blue is too high [7]. It can produce a burning sensation through oral intake, and may cause nausea, vomiting, sweating, mental disorder and methemoglobinemia, etc [8]. At present, several countries or institutions, including USA, EU and Japan, have formulated for the detection of methylene blue residues in aquatic products.…”

“…NRS was pretreated using epichlorohydrin and concentrated H 2 SO 4 in various impregnation ratios to produce modified NRS called NRSEA. The results of MB adsorption ability test onto NRSEA showed that the adsorption capacity increased with increasing pH (within the pH range of [7][8][9][10][11][12] and decreased afterwards, the optimum initial MB concentration reached at 800 mg/L, and the equilibrium state was achieved at 120 min of contact time. Enhanced methylene blue removal from aqueous solution using modified rubber seed (Hevea brasiliensis).…”