David Bacon, MD
Assistant Professor
University of Kentucky College of Medicine
Lexington, Kentucky, United States
Disclosure information not submitted.
Title: eICU-Assisted Diagnosis of Buprenorphine/Naloxone-Induced Serotonin Syndrome
Case Report Body:
Introduction: Serotonin syndrome (SS) is a potentially life-threatening disorder associated with increased serotonergic activity in the CNS and PNS. The diagnosis is clinical, and typically presents with well-defined features of altered mental status, autonomic dysfunction, and neuromuscular excitation. Still, the diagnosis remains elusive due to the variable clinical presentation and the overlap of symptoms with other conditions. With the increasing number of patients taking antidepressant medications and the extensive list of medications causing SS, it is likely underdiagnosed, thus clinicians must maintain a high index of suspicion. We present a case of SS after the administration of buprenorphine/naloxone (B/N) and highlight use of an eICU intensivist in making a clinical diagnosis.
Description: A 43-year-old male with a history of bipolar disorder (on home duloxetine and lamotrigine) and polysubstance abuse was admitted to our hospital following a left pilon fracture s/p ORIF. Post-operatively he was started on B/N. Approximately 3 hours after initial dosing, he developed severe agitation, diaphoresis, tachycardia, tachypnea, and pyrexia, and was diagnosed with opioid withdrawal (W/D). After transfer to the ICU due to concern for airway compromise, the nocturnist ICU team (an APP at bedside and an intensivist in a remote eICU) collaborated via a 2-way video to discover the additional findings of mydriasis, hyperreflexia, and inducible clonus. Upon review of the patient’s medical record, the diagnosis of SS was made, the precipitating agents were discontinued, and supportive therapy initiated. He fully recovered in approximately 24 hours.
Discussion: The importance of this case is twofold. Patients treated for opioid use disorder are often prescribed B/N to prevent opioid W/D in addition to medications with serotonergic activity for mood stabilization or as components of a multimodal pain regimen. In our case, the addition of B/N precipitated SS. The symptoms of SS can be mistaken for opioid W/D, delaying management and making an unfavorable prognosis more likely.
Secondly, as the implementation of APP-managed ICU service lines expand, there is value to having an eICU intensivist to assist in assessing and managing patients, even in cases requiring a thorough physical examination to make a clinical diagnosis.