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A Case of Postoperative Serotonin Syndrome Following the Administration of Fentanyl, Palonosetron, and Meperidine -A Case Report

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A Case of Postoperative Serotonin Syndrome Following the Administration of Fentanyl, Palonosetron, and Meperidine -A Case Report Anesth Pain Med 2015; 10: 267-270 http://dx.doi.org/10.17085/apm.2015.10.4.267 ￭Case Report￭ A case of postoperative serotonin syndrome following the administration of fentanyl, palonosetron, and meperidine -A case report- Department of Anesthesiology and Pain Medicine, Daegu Fatima Hospital, Daegu, *Department of Psychiatry, Ulsan University Hospital, Ulsan, Korea Chiu Lee, Eun-Ju Kim, Soohyun Joe*, Jong Seouk Ban, Ji-hyang Lee, and Ji-hyun An Serotonin syndrome is an unexpected adverse reaction of seroto- antagonists. nergic medication. Some drugs used by anesthesiologists may In this study, we present the first case of fentanyl- and cause serotonin syndrome. Serotonin syndrome is known to be meperidine-induced SS precipitated by palonosetron in general related to 5-hydroxytryptamine 1A and 5-hydroxytryptamine 2A agonism. However, recent research has revealed evidence that anesthesia. 5-hydroxytryptamine 3 (5-HT3) antagonism can also play a role in serotonin syndrome. Among the 5-HT3 antagonists, palonosetron is the most highly specific. In this study, we present the first case CASE REPORT of fentanyl- and meperidine-induced serotonin syndrome precipi- tated by palonosetron in general anesthesia. (Anesth Pain Med An emergency appendectomy for acute appendicitis was 2015; 10: 267-270) performed in a 51-year-old male. Preoperatively, he had been treated with losartan, thiazide, and atorvastatin for hypertension Key Words: Fentanyl, Meperidine, Palonosetron, Serotonin, Serotonin syndrome. and hyperlipidemia for years. He had no other medication, including a serotonergic agent, for at least two months before admission. He had received lumbar discectomy 10 years prior The 5-hydroxytryptamine 1A (5-HT1A) or 5-hydroxytryptamine and had no known lifetime history of allergies, shock, or 2A (5-HT2A) agonism is commonly known to be coupled with perioperative event. His physical status classification was serotonin syndrome (SS). However, evidence shows that American Society of Anesthesiologists physical status Classifi- 5-hydroxytryptamine 3 (5-HT3) antagonism may result in SS. cation II. His electrocardiogram, laboratory tests, and preopera- Previously, 5-HT3 antagonists granisetron [1] and ondansetron tive vital signs were unremarkable. About 8 and 7 h before [2,3] were reported to be associated with SS in the presence the onset of SS, 50 mg tramadol was injected at each time to of concomitant serotonergic medication. Among 5-HT3 anta- control pain from appendicitis. No other potentially serotonergic gonists, palonosetron is unique because it is highly selective, agent was administered before surgery. and theoretically it may precipitate SS more than other 5-HT3 On the day of surgery, preoperative vital signs were blood pressure of 100/60 mmHg, heart rate of 82 beats/min, pulse Received: April 28 2015. oxygen saturation of 97% on room air, respiratory rate of 13 Revised: 1st, June 18, 2015; 2nd, July 1, 2015. breaths/min, and body temperature through the tympanic mem- Accepted: July 8, 2015. brane of 36.7oC. Corresponding author: Eun-Ju Kim, M.D., Department of Anesthesiology General anesthesia was induced with 2 mg/kg propofol, 1 and Pain Medicine, Daegu Fatima Hospital, 99, Ayang-ro, Dong-gu, Daegu g/kg fentanyl, and 0.6 mg/kg rocuronium. After tracheal 41199, Korea. Tel: 82-53-940-7434, Fax: 82-53-940-7443, E-mail: [email protected] intubation, anesthesia was maintained with 6% desflurane and 50% nitrous oxide in oxygen. Palonosetron was administered 5 This is an Open Access article distributed under the terms of the Creative Commons min after induction to prevent postoperative nausea and vomi- Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any ting. The patient was hemodynamically stable until surgery was medium, provided the original work is properly cited. done uneventfully. His body temperature through the esophagus 267 268 Anesth Pain Med Vol. 10, No. 4, 2015 was 36.6–36.7oC. End-tidal carbon dioxide was maintained cations and sequelae. between 30 and 35 mmHg during surgery. Neuromuscular block was reversed by 0.2 mg glycopyrrolate DISCUSSION and 10 mg pyridostigmine. A tracheal tube was extubated. The patient being able to lift his head for 5 s and sustaining a Serotonin is a neurotransmitter involved in mood, hand grip for 5 s ensured no residual neuromuscular blockade. personality, emesis, appetite, pain perception, sexual behavior, The total operating time was about 30 min. After confirming temperature regulation, hormone regulation, and wakefulness full recovery from neuromuscular blockade and with an alert [4]. SS is a toxic state resulting from the increased seroto- mental status, the patient was transferred to the post-anesthetic nergic neurotransmission in the postsynaptic neuron [5]. Serotonin care unit. toxicity generally occurs in patients who have ingested drug In the post-anesthetic care unit, the patient did not complain combinations that synergistically increase synaptic serotonin or of any postoperative nausea and vomiting (PONV) or pain, his have taken one medication in a high dose [5]. Monoaminergic mental status was alert, his vital signs were normal, and his neurotransmitters, N-methyl-d-aspartate receptor antagonists, and visual analogue scale was 3 for about 30 min. Intravenous γ-aminobutyric acid have also been suggested to affect SS meperidine of 25 mg was administered to the patient when he development, and they provide evidence that other neuro- had mild shivers. Immediately after the injection of meperidine, transmitters may also play a role [4]. A large number of the shivering that seemed like a clonus exacerbated rather than medications, antidepressants, opioids, and central nervous sys- subsided, and the patient showed diaphoresis and agitation. tem stimulants, among others, can cause SS (Table 1) [4]. Moreover, his mental status became drowsy and confused. The symptoms of SS are akathisia, tremor, altered mentality, Tachypnea and fever (38.8oC) were determined at that time. clonus, muscular hypertonicity, and hyperthermia. The symptoms SS was suspected, and immediate supportive management that are specific and have a wide spectrum from mild to life included tepid massage and rapid intravenous ice-cold normal threatening. saline (500 ml/h) was conducted. Nevertheless, the patient’s No laboratory test can confirm SS. Therefore, diagnosis is body temperature reached 39.2oC. His blood pressure reached conducted through the evaluation of symptoms and patient's 182/94 mmHg, and his maximal heart rate was 120 beats/min. history. Sternbach’s Serotonin Toxicity Criteria [6] are the first Oxygen saturation was low at 94% on the 6 L/min O2 reserve strictly evaluated standard. Sternbach’s Serotonin Toxicity bag. Respiration was shallow and as fast as 26 breaths/min. Criteria [6] for SS are as follows: (1) recent addition of a ABGA was checked (pH 7.382, PCO2 39.6 mmHg, PO2 82.2 serotonergic agent, (2) absence of other possible etiologies, (3) − mmHg, HCO3 23.0 mM/L, and O2 saturation 96%), and his blood sugar was normal. To control hypertension, 2.5 mg labetalol and 1 mg nicardipine were injected. Cyproheptadine, a 5-HT antagonist, was considered, but it was not administered because of the patient’s poor cooperation due to confused mentality. The patient’s mental status, vital signs, and accompanying symptoms, such as agitation and diaphoresis, gradually recovered 3 h after the onset of SS (Fig. 1). His vital signs were blood pressure of 120/80 mmHg, heart rate of 80 beats/min, respiratory rate of 20 breaths/min, and body temperature through the tympanic membrane of 36.5oC. After the patient recovered, he was transferred to the general ward from the post-anesthetic care unit. No more potentially serotonergic agent and palonosetron were administered since SS occurred. In the general ward, the patient did not complain of any PONV. Acetaminophen and ketorolac were administrated for Fig. 1. Time course of the changes in vital signs. SBP: Systolic blood pressure, DBP: Diastolic blood pressure, HR: Heart rate, RR: Respiratory his pain. He was eventually discharged without any compli- rate, BT: Body temperature. Chiu Lee, et al：Palonosetron in serotonin syndrome 269 Table 1. Drugs Associated with Serotonin Syndrome Table 2. The Hunter Serotonin Toxicity Criteria: Decision Rules Antidepressants In the presence of a serotonergic agent, Bupropion, nefazodone, trazodone, mirtazapine, tapentadol, mo- 1. IF (spontaneous clonus = yes) THEN serotonin toxicity = YES noamine oxidase inhibitors, tricyclic antidepressants, selective se- 2. ELSE IF (inducible clonus = yes) AND [(agitation = yes) rotonin reuptake inhibitors, serotonin norepinephrine reuptake inhi- OR (diaphoresis = yes)] THEN serotonin toxicity = YES bitors 3. ELSE IF (ocular clonus = yes) AND [(agitation = yes) Opioids OR (diaphoresis = yes)] THEN serotonin toxicity = YES Tramadol, meperidine, fentanyl, pentazocine, buprenorphine, oxy- 4. ELSE IF (tremor = yes) AND (hyperreflexia = yes) codone, hydrocodone THEN serotonin toxicity = YES Central nervous system stimulants 5. ELSE IF (hypertonic = yes) AND (temperature ＞ 38oC) 3,4-Methylenedioxymethamphetamine, phentermine, diethylpropion, AND [(ocular clonus = yes) OR (inducible clonus = yes)] amphetamine, cocaine, sibutramine, methylphenidate, metham- then serotonin toxicity = YES phetamine 6. ELSE serotonin toxicity = NO 5-HT1 agonists Triptans Psychedelics patient had susceptibility
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