2.2 SFGH AM report pearls: serotonin syndrome!

  • While NMS is classically caused by neuroleptic agents (mainly typical antipsychotics), it is known to occur in Parkinson’s patients in the setting of withdrawal/dose reduction of dopamine agonist therapy or switching from one dopamine agonist to another.
    • NMS and serotonin syndrome have a few distinguishing features highlighted in the graphic below, courtesy of Michelle Yu, one our ICU/pulm fellows!
    • SS vs NMS
    • MAOIs have the greatest risk of causing serotonin syndrome, but SSRIs are a much more common cause, as they are far more widely prescribed
  • Hyperthermia management – for T>41, patients should be intubated, sedated and paralyzed to minimize heat generation by muscle metabolism
    • Remember that anti-pyretics won’t work for this!
  • Rasagaline is an MAO B inhibitor thought to be modestly effective for Parkinsonian symptoms. Trials of selegeline, a similar drug, show potential delay in progression of the disease process, though risks have to be weighed (as evidenced in this case)
    • Unlike the non-selective MAOIs, MAO B inhibitors do not precipitate hypertensive crisis if the patient consumes excess tyramine
  • Procalcitonin is a calcitonin precursor released from parenchymal cells in response to bacterial infections and downregulated in response to viral infections and other inflammatory conditions.
    • This is only be sent in the ICU at SFGH, and can be helpful (taken in context with other data) in determining whether a patient needs to be continued on antibiotics

Evernote link: https://www.evernote.com/shard/s300/sh/5e0fdc03-7e4f-45f8-a8bc-b3ca0c118eab/50c257ea484729238eb0d7c473fe5086




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