Serotonin Syndrome Precipitated by Fentanyl During Procedural Sedation

Kirschner, Ron; Donovan, J. Ward

doi:10.1016/j.jemermed.2008.01.003

Cited by 36 publications

(16 citation statements)

References 19 publications

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“…It is possible that the prolonged duration of the serotonin syndrome was the result of fentanyl administration in the intensive care unit. Although causality has not been clearly established on rare occasion, fentanyl has been associated with serotonin syndrome [13]. Nonetheless, the patient clearly had toxicity manifested prior to the onset of fentanyl and we feel fentanyl is unlikely to be the primary cause of the relatively long duration of symptoms.…”

Section: Discussionmentioning

confidence: 79%

Recurrent Seizures and Serotonin Syndrome Following “2C-I” Ingestion

2013

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The phenethylamines, including 2, 5 dimethoxy-4-iodophenethylamine, commonly referred to as 2C-I, have recently emerged as a new class of designer drugs. Cases of toxicity from these drugs are not well described in the literature. This case report describes a 19 year-old male who insufflated 2C-I. Following the ingestion, the patient developed recurrent seizures, and was taken to the emergency department, where he was noted to be hyperadrenergic and had recurrent seizures. The patient was diagnosed with serotonin syndrome and experienced prolonged respiratory failure, although he ultimately made a full recovery. Comprehensive drug testing revealed the presence of 2C-I. The pharmacologic properties of 2C-I are also discussed.

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Section: Discussionmentioning

confidence: 79%

Recurrent Seizures and Serotonin Syndrome Following “2C-I” Ingestion

2013

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“…Remifentanil, with no evidence so far that it reacts adversely with a MAOI and with a short elimination half-life of 5e8 min, was selected and used safely in major surgery as part of a balanced anaesthetic technique in a patient treated with phenelzine. 81 Gillman 45 and Kirschner and Donovan 59 have drawn attention to an atypical case of low-dose fentanyl-induced muscle rigidity during recovery from anaesthesia in an adult patient on venlafaxine, who was also given a single dose of meperidine before the procedure. 82 Although a diagnosis of ST was not considered, symptoms including hyperreflexia and ankle clonus, prompted speculation that chest wall rigidity in some other patients taking serotonergic drugs 83,84 may be a manifestation of ST.…”

Section: Fentanylmentioning

confidence: 99%

The anaesthetist, opioid analgesic drugs, and serotonin toxicity: a mechanistic and clinical review

Baldo

Rose

2020

British Journal of Anaesthesia

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Most cases of serotonin toxicity are provoked by therapeutic doses of a combination of two or more serotonergic drugs, defined as drugs affecting the serotonin neurotransmitter system. Common serotonergic drugs include many antidepressants, antipsychotics, and opioid analgesics, particularly fentanyl, tramadol, meperidine (pethidine), and methadone, but rarely morphine and other related phenanthrenes. Symptoms of serotonin toxicity are attributable to an effect on monoaminergic transmission caused by an increased synaptic concentration of serotonin. The serotonin transporter (SERT) maintains low serotonin concentrations and is important for the reuptake of the neurotransmitter into the presynaptic nerve terminals. Some opioids inhibit the reuptake of serotonin by inhibiting SERT, thus increasing the plasma and synaptic cleft serotonin concentrations that activate the serotonin receptors. Opioids that are good inhibitors of SERT (tramadol, dextromethorphan, methadone, and meperidine) are most frequently associated with serotonin toxicity. Tramadol also has a direct serotonin-releasing action. Fentanyl produces an efflux of serotonin, and binds to 5hydroxytryptamine (5-HT) 1A and 5-HT 2A receptors, whilst methadone, meperidine, and more weakly tapentadol, bind to 5-HT 2A but not 5-HT 1A receptors. The perioperative period is a time where opioids and other serotonergic drugs are frequently administered in rapid succession, sometimes to patients with other serotonergic drugs in their system. This makes the perioperative period a relatively risky time for serotonin toxicity to occur. The intraoperative recognition of serotonin toxicity is challenging as it can mimic other serious syndromes, such as malignant hyperthermia, sepsis, thyroid storm, and neuroleptic malignant syndrome. Anaesthetists must maintain a heightened awareness of its possible occurrence and a readiness to engage in early treatment to avoid poor outcomes.

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“…However, many cases occur after exposure to 2 or more drugs that increase the serotonin activity. Examples of combinations of proserotonergic medications causing serotonin syndrome include reports of SSRIs and fentanyl (given during procedural sedation), 102 erythromycin, 96 and St John's wort (an over-the-counter herbal supplement). 95 In addition, serotonin syndrome has also been reported in a patient withdrawing from a serotonergic agent.…”

Section: Pathophysiologymentioning

confidence: 99%