The Serotonin Syndrome: From Molecular Mechanisms to Clinical Practice.

The serotonin syndrome is a medication-induced condition resulting from serotonergic hyperactivity, usually involving antidepressant medications. As the number of patients experiencing medically-treated major depressive disorder increases, so does the population at risk for experiencing serotonin syndrome. Excessive synaptic stimulation of 5-HT2A receptors results in autonomic and neuromuscular aberrations with potentially life-threatening consequences. In this review, we will outline the molecular basis of the disease and describe how pharmacologic agents that are in common clinical use can interfere with normal serotonergic pathways to result in a potentially fatal outcome. Given that serotonin syndrome can imitate other clinical conditions, an understanding of the molecular context of this condition is essential for its detection and in order to prevent rapid clinical deterioration.

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

BACKGROUND: 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.