Delirium In ICU Patients May Be Just Serotonin Syndrome

[haidut]

I have several friends who are ER physicians and one of them works in the ICU as well. The topic of post-surgical delirium has come up many times and all of them vehemently denied that serotonin has anything to do with it. The current view is that the mechanism and cause is unknown and heredity probably has a big role, as well as prior/current substance abuse. The fact that delirium shares most of the signs/symptoms of serotonin syndrome is simply brushed aside as coincidence.
Well, once again, serotonin seems to be rearing its ugly head. This study found that a significant portion of ICU patients with delirium have serotonin syndrome. The sad part is that, just like my doctor friends, the attending doctors completely failed (or ignored) to properly recognize the condition and treat it appropriately with cyproheptadine. Another recent trial found that low dose cyproheptadine prevented most cases of delirium even though it did not do much for very severe cases already in progress. I suppose the even sadder part is that many ICU patients are treated with SSRI or other serotonergic drugs to "calm" them down. Given the direct effect of these drugs on inducing serotonin syndrome I wonder if the failure to recognize the connection is pure stupidity or is it being purposefully ignored to avoid implicating blockbuster drugs that make tons of money for the hospital...

Annals of Intensive Care
"...Delirium is a frequently occurring syndrome in patients admitted to the intensive care unit (ICU) or medium care unit (MCU), yet the pathophysiology remains poorly understood. An excess of central serotonin can lead to an altered mental status, associated with autonomic hyperactivity, and neuromuscular excitation. Drugs with serotonergic properties are frequently and for prolonged periods administered to ICU/MCU patients. Therefore, central serotonergic toxicity may constitute a predisposing, contributing or precipitating factor in the emergence of delirium. The purpose of the present study is to determine the number of patients admitted to the ICU or MCU who are diagnosed with delirium and who show characteristics of serotonin toxicity in association with the administration of serotonergic drugs."

"...A significant proportion of delirious patients in the ICU might in fact be classified as suffering from central serotonin toxicity. The awareness of potential serotonin toxicity is low among physicians."

 

[Blossom]

I wonder about the possibility of acetaminophen and opioid meds in combination with acetaminophen that are often given every 4-6 hours routinely around the clock to ICU patients contributing? Perhaps this could be connected to the development of serotonin syndrome since acetaminophen seems to raise serotonin.
Acetaminophen raises serotonin/adrenaline, aspirin lowers it

 

[haidut]

I wonder about the possibility of acetaminophen and opioid meds in combination with acetaminophen that are often given every 4-6 hours routinely around the clock to ICU patients contributing? Perhaps this could contribute to the serotonin syndrome since acetaminophen seems to raise serotonin.
Acetaminophen raises serotonin/adrenaline, aspirin lowers it

Yep, as soon as I saw you mentioning acetaminophen I thought of that link about aspirin/acetaminophen antagonizing each other. Acetaminophen is actually an inducer of TPH - the enzyme that synthesizes serotonin. The incidence of serotonin syndrome has risen sharply over the last decade and the curve matches perfectly the curve of increase of acetaminophen usage. Tylenol is now THE de-facto standard now for managing moderate to severe pain in hospitals if the patient refuses opioids or cannot take them for whatever reason. Doctors would not touch aspirin and ibuprofen has a heart attack warning so doctor try to avoid it as well.
The irony is that Tylenol actually works through serotonin and opioid receptors itself and makes things much worse in the long run.
Anyways, I am glad we saw the same connection

 

[Such_Saturation]

Well cyproheptadine is also a calcium blocker...

 

[Blossom]

Oh no, here I go again...Perhaps outcomes would be improved if there was more understanding about the impact these commonly prescribed meds actually have on people. Sigh... I'm not a pharmacist though so what do I know!?! Enough to know what I don't want given to me unknowingly thanks to Peat, our discussions here and my own common sense.

My 'drug allergy' list currently includes SSRI's, Statins and PPI's just because I do not want to be put on these meds against my will and yes, I diagnosed myself with these allergies. Maybe I'll add acetaminophen (and lactated ringers solution!) to the list on the off chance that I ever end up in a coma in the ICU and can't speak for myself.

In all fairness I appreciate that we have emergency services and intensive care units that actually save lives that might otherwise be lost. I also appreciate that the actual workers for the most part are well intentioned and believe they are doing the right things. I still think it's prudent that the medical community continue to explore the safest treatments possible because of iatrogenic harm which goes above and beyond the fact that medical errors were the third leading cause of death in the U.S. the last time I checked.

Sorry if I derailed your thread haidut. I'm a bit passionate when it comes to people being harmed by medicine having personally experienced it myself from both sides of the fence so to speak.

 

[MommaBear]

Doesnt acetaminophen also cause issues with the MTHFR gene defect?