Serotonin Syndrome Following Methylene Blue Administration During Cardiothoracic Surgery

Smith, Christina T.; Wang, Dorothy; Sgambelluri, Anna; Kramer, Robert S.; Gagnon, David J.

doi:10.1177/0897190014568389

Cited by 20 publications

(8 citation statements)

References 23 publications

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“…MB is a reversible monoamine oxidase inhibitor and its use in cardiac surgery and peri-operatively for diagnostic purposes has been associated with SS. [14,15] This happened in normal patients taking therapeutic doses of either a selective serotonin reuptake inhibitor (SSRI) or selective noradrenaline reuptake inhibitors (SNRI) who received 1-2 mg/kg intravenous MB prior to surgery and developed mild to moderate SS. [15] Moreover, this reaction can be fatal, with one case report of a 75-year-old patient on therapeutic doses of venlafaxine, given 1 g (9 mg/kg) intravenous MB prior to surgery, who developed severe SS and died.…”

Section: Discussionmentioning

confidence: 99%

“…[14,15] This happened in normal patients taking therapeutic doses of either a selective serotonin reuptake inhibitor (SSRI) or selective noradrenaline reuptake inhibitors (SNRI) who received 1-2 mg/kg intravenous MB prior to surgery and developed mild to moderate SS. [15] Moreover, this reaction can be fatal, with one case report of a 75-year-old patient on therapeutic doses of venlafaxine, given 1 g (9 mg/kg) intravenous MB prior to surgery, who developed severe SS and died. [14] MB is a potent, concentrationdependent, reversible monoamine oxidase (MAO-A) inhibitor and has an active metabolite (azure B) which is thought to be at least 6 times more potent as an MAO-A inhibitor and readily penetrate into the brain tissue.…”

Section: Discussionmentioning

confidence: 99%

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Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome

et al. 2017

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome

et al. 2017

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“…The 14 cases, along with their characteristics, etiology, symptomatology, treatment, and outcome, are presented Table 1. [1][2][3][4][5][6][7][8][9] All documented cases occurred within the last 9 years and 11 of 14 occurred within the last 2 years, which suggests a recent emergence in cardiology attributed to either increasing incidence, improving recognition, or both concurrently. One common thread between all 14 cases is onset after fentanyl and/or MB administration.…”

Section: Discussionmentioning

confidence: 99%

Methylene blue–induced serotonin syndrome after left ventricular assist device implantation: A case report and literature review

Schumacher

Blumer

Chaparro

2017

The Journal of Thoracic and Cardiovascular Surgery

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Video clip is available online. Serotonin syndrome is a life-threatening condition of serotonin excess in the central nervous system. We report the first case to occur after a routine left ventricular assist device (LVAD) implantation. Through a systematic review of the literature, we then describe the characteristics of all previous patients with serotonin syndrome after cardiovascular procedures and identify common threads that elucidate serotonin syndrome's recent emergence. CASE PRESENTATION A 60-year-old Hispanic man with a medical history of coronary artery bypass graft, hypertension, atrial fibrillation, obesity, obstructive sleep apnea, depression, and ischemic cardiomyopathy with ejection fraction 10% to 15% was admitted for heart failure exacerbation. Right and left heart catheterizations showed nonobstructive coronary artery disease and increased right-sided heart pressures. He subsequently developed cardiogenic shock requiring intra-aortic balloon pump and inotropic support with milrinone. Eleven days later, he underwent LVAD implantation. General anesthesia required fentanyl, midazolam, rocuronium, dexmedetomidine, and etomidate. He required vasopressor and inotropic support with norepinephrine, epinephrine, and milrinone. He also received prophylactic antibiotic treatment with vancomycin, cefepime, and fluconazole. The operation was successful with no complications, and the patient recovered appropriately from anesthesia. VIDEO 1. A video describing the unique aspects of this case report followed by the key findings from a review of all serotonin syndrome cases in the cardiology literature.

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“…Furthermore, it has been used in the treatment of methemoglobinemia, cyanide poisoning, and refractory vasoplegia in cardiothoracic surgery [ 11 , 12 ]. Patients undergoing cardiothoracic surgery are especially at risk of developing serotonin syndrome because of the high incidence of post-cardiopulmonary bypass vasoplegia requiring the use of methylene blue [ 13 – 16 ]. Given the concern for this complication, the FDA published a Drug Safety Communication in 2011, which cautioned about the risk of central nervous system reactions in patients taking serotonergic psychiatric medications who are exposed to methylene blue [ 2 , 7 , 12 , 17 – 19 ].…”

Section: Discussionmentioning

confidence: 99%

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

2016

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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.

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Serotonin Syndrome Following Methylene Blue Administration During Cardiothoracic Surgery

Cited by 20 publications

References 23 publications

Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome

Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome

Methylene blue–induced serotonin syndrome after left ventricular assist device implantation: A case report and literature review

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

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