Neurocritical Care

Intravenous immunoglobulin 0.4 g/kg/day × 3–5 days or plasmapheresis 20–25 mL/kg plasma × 5

exchanges every other day × 10 days

Similarly effective; can choose according to patient risk factors, etc.

taper)

Supportive Care – Consider discontinuing cholinergic therapies while the patient is acutely ill. May

increase pulmonary secretions and complicate ventilator/ICU management

Autonomic hyperactivity (hypertension, tachycardia)

Hyperthermia – Diaphoresis

Seizures

Neuromuscular abnormalities

Rigidity

Hyperreflexia and clonus

Shivering

Diarrhea

caused by a single therapeutic agent, a combination of agents, or overdose. Common serotonergic drugs

are listed in Table 15.

features are listed in Table 16.

Drug Class

Associated Drugs

Antiemetics

Ondansetron, granisetron, metoclopramide

Antiepileptics

Lamotrigine, carbamazepine, valproic acid

Anti-migraine

Triptans, ergotamine, methylergonovine

Herbal products

St. John’s wort, tryptophan, ginseng

Illicit drugs

Methamphetamine, amphetamine, ecstasy (MDMA), psilocybin, LSD

Opioids

Fentanyl, meperidine, methadone, dextromethorphan, tramadola

SSRIs

Citalopram,a fluoxetine,a sertraline,a escitalopram, paroxetine

SNRIs

Venlafaxine, duloxetine

TCAs

Amitriptyline, clomipramine, imipramine

MAOIs

Phenelzine, rasagiline, selegiline

Others

Bupropion,a buspirone, lithium, trazodone

Miscellaneous

Linezolid, cyclobenzaprine, methylene blue, fluconazole,

chlorpheniramine

aTop 5 agents implicated in serotonin syndrome

MAOIs = monoamine oxidase inhibitors; SNRIs: serotonin and norepinephrine reuptake inhibitors; SSRIs: selective serotonin reuptake inhibitors; TCAs: tricyclic

antidepressants.

Information from: Mikkelsen N, Damkier P, Arnspang Pedersen S. Serotonin syndrome – a focused review. Basic Clin Pharmacol Toxicol 2023;133:124-9; Pedavally S,

Fugate JE, Rabinstein AA. Serotonin syndrome in the intensive care unit: clinical presentations and precipitating medications. Neurocrit Care. 2014;21:108-13.