Recurrent Serotonin Syndrome After Ketamine-assisted Electroconvulsive Therapy: A Case Report and Review of the Literature.

IF 1.3 4区 医学 Q3 PSYCHIATRY
Aniruddha Deka, Emmanuel Joseph, Neha Sharma, Tirsit Berhanu, Jonathan Kaplan
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引用次数: 0

Abstract

Serotonin (5-HT) syndrome (SS) consists of changes in mental status as well as autonomic and neuromuscular changes. Though not well understood, serotonergic pathways have been implicated in the mechanism of action of electroconvulsive therapy (ECT). Ketamine has been used as an induction agent in ECT and as therapy for treatment-resistant depression. Utilizing a case report and literature review, we explored the underlying serotonergic mechanisms of ECT and ketamine by which a syndrome of serotonin toxicity may be precipitated. We describe the case of a 72-year-old woman who developed recurrent SS on 2 occasions in similar circumstances involving the administration of ketamine for ECT. In our literature review, we found 5 cases in which SS was associated with ECT and 1 case linking ketamine to SS. There is emerging evidence that the mechanism of ECT involves 5-HT1A and 5-HT2A receptors, the same receptors that are involved in SS. ECT can transiently increase the permeability of the blood-brain barrier, leading to increased levels of antidepressants in the brain. ECT can, therefore, enhance 5-HT transmission and the likelihood of SS in the presence of serotonergic agents. The effect of ketamine on 5-HT transmission is mediated by the glutamate α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor. Ketamine increases α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid activity in the medial prefrontal cortex, which leads to downstream 5-HT release through glutamate. Through this mechanism, ketamine can increase 5-HT transmission, leading to SS. To our knowledge, this is the only case report of recurrent SS with concurrent use of ECT and ketamine. As ketamine is frequently used in ECT and many patients undergoing ECT are on serotonergic medications, it is important to recognize ketamine as a potential risk factor for SS. There is no evidence for added efficacy when combining ECT and ketamine. Thus, one should proceed with caution when combining these treatments. The burgeoning use of ketamine in ambulatory settings makes it necessary to elucidate the risks, which we discuss further. More research is needed into the mechanisms of ketamine and ECT, specifically how the combination of these treatments influence 5-HT levels.

氯胺酮辅助电休克疗法后的复发性羟色胺综合征:病例报告和文献综述。
血清素(5-HT)综合征(SS)包括精神状态的变化以及自主神经和神经肌肉的变化。尽管还不十分清楚,但血清素能通路与电休克疗法(ECT)的作用机制有关。氯胺酮一直被用作电休克疗法的诱导剂和治疗耐药抑郁症的药物。通过病例报告和文献综述,我们探讨了 ECT 和氯胺酮可能引发血清素中毒综合征的潜在血清素能机制。我们描述了一名 72 岁女性的病例,她在类似的情况下,两次使用氯胺酮进行电痉挛治疗,均反复出现血清素中毒综合征。在文献综述中,我们发现5例SS与电痉挛疗法有关,1例氯胺酮与SS有关。有新的证据表明,电痉挛疗法的机制涉及 5-HT1A 和 5-HT2A 受体,这些受体也与 SS 的受体有关。ECT 可短暂增加血脑屏障的通透性,导致脑内抗抑郁药物水平升高。因此,在有血清素能药物存在的情况下,ECT 可以增强 5-HT 的传递,增加 SS 的可能性。氯胺酮对 5-HT 传递的影响由谷氨酸α-氨基-3-羟基-5-甲基-4-异恶唑丙酸受体介导。氯胺酮会增加内侧前额叶皮层中α-氨基-3-羟基-5-甲基-4-异恶唑丙酸的活性,从而通过谷氨酸导致下游 5-HT 的释放。通过这种机制,氯胺酮可以增加 5-HT 的传递,从而导致 SS。据我们所知,这是唯一一例同时使用电痉挛疗法和氯胺酮的复发性 SS 病例报告。由于氯胺酮经常用于电痉挛疗法,而且许多接受电痉挛疗法的患者都在服用血清素能药物,因此必须认识到氯胺酮是导致 SS 的潜在风险因素。没有证据表明 ECT 与氯胺酮合用会增加疗效。因此,在结合使用这些疗法时应谨慎行事。随着氯胺酮在非住院环境中的广泛使用,有必要阐明其风险,我们将对此进行进一步讨论。我们需要对氯胺酮和电痉挛疗法的机制进行更多的研究,特别是这两种疗法的结合如何影响5-羟色胺水平。
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来源期刊
CiteScore
2.30
自引率
10.50%
发文量
159
审稿时长
>12 weeks
期刊介绍: Journal of Psychiatric Practice® seizes the day with its emphasis on the three Rs — readability, reliability, and relevance. Featuring an eye-catching style, the journal combines clinically applicable reviews, case studies, and articles on treatment advances with practical and informative tips for treating patients. Mental health professionals will want access to this review journal — for sharpening their clinical skills, discovering the best in treatment, and navigating this rapidly changing field. Journal of Psychiatric Practice combines clinically applicable reviews, case studies, and articles on treatment advances with informative "how to" tips for surviving in a managed care environment.
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