Critical Care Medicine | 2019
142: ZEBRAS THAT BLOW MINDS ATRIOESOPHAGEAL FISTULA AFTER ATRIAL FIBRILLATION ABLATION
Abstract
Learning Objectives: Serotonin syndrome is a rare consequence of excess serotonergic agonism of central and peripheral nervous system receptors. It is often described as a triad of mental status changes, autonomic hyper-reactivity, and neuromuscular abnormalities. The majority of cases of serotonin syndrome present within 24 hours of a change of dose or initiation of a drug. We present a particularly challenging case of serotonin syndrome diagnosed in the ICU setting in a patient on venovenous extracorporeal membrane oxygenation (V-V ECMO). Methods: The patient was a 36 yo male who was emergently placed on VV ECMO after a peri-procedural aspiration event resulting in refractory hypoxia secondary to ARDS His ICU course was complicated by worsening hypoxia, episodes of hyper/hypotension and tachycardia, rigors and fevers. The patient was receiving sertraline and aripiprazole for his anxiety and depression and sedation was continued on propofol, midazolam and hydromorphone. The patient was given meperidine for shivering, and shortly thereafter developed new onset clonus, rigidity and tremors. He also developed an elevated creatinine phosphokinase (CPK) level and elevated creatinine. These findings prompted concern for serotonin syndrome and the neurology team agreed after evaluation. The patient’s serotonergic medications were held, midazolam was restarted and he was started on cyproheptadine. The patient returned to baseline in 72 hours and went on to make a full recovery. Results: Typically, serotonin syndrome starts usually within hours of medication initiation, a dose increase, or overdose. Serotonin syndrome will continue as long as the serotonergic agents remain in the system. Prognosis is generally favorable for patients with serotonin syndrome as long as it is promptly recognized and its associated complications are treated appropriately (supportive care and cyproheptadine). It is a clinical diagnosis but can be supported by certain lab values including elevated CPK levels secondary to associated rhabdomyolysis. There are no published case reports of serotonin syndrome in an ECMO patient. It is important to recognize that these highly complex patients who require large doses of anesthesia in an ICU setting can suffer complications that are typically seen in OR populations. If unrecognized, serotonin syndrome can be fatal CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MDCCM