As of last night, April 30th 2008, my dad was basically in a medically induced coma. I asked his nurse what the difference was, and one of the medicines is the same, but a different dose, and they have a second medicine that they don't usually use for the coma. So it's very similar. It's scary to see him in this state; tubes, wires, lines, etc., but it's a relief because he's finally resting. It's been so long since he's actually been able to sleep without tremors. It's actually been so long since he's been able to sleep at all.
His pneumonia is being treated with antibiotics and his fever gradually lowered last night.
4 out of 5 of his doctors have said that they think he has Serotonin Syndrome (info below). His 5th doctor, his psychiatrist, says that he thinks it's neuroleptic malignant syndrome. Information is listed for both in the article below. The "tables" aren't really tables. I can't get them to paste correctly, but there's a link here and at the bottom of this page to the original website.
The first email is one that I sent out to new people, as requested by my mom, so there's an update and background. I realize a lot of this is repeated, but I just copied and pasted info from other emails.
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[April 30, 2008]
Hello-On behalf of my parents, Donn & Kayrene Anderson, I'm sending out an email with a medical health update on my dad. Some of you may have already received this from other people (I just got your email addresses from my parents' email accounts), but just in case you haven't, here it is.
My dad is staying at Edward Hospital in Naperville, IL. He first was admitted late Saturday night, April 19th. Then he was released on Friday night, April 25th and sent to Snow Valley Nursing home for physical therapy. My mom first had him brought in because he had been shaking so much he couldn't sleep and had trouble even moving. The final point was when they decided my mom would drive him to the ER, but he felt like his feet were glued to the ground, so they had to call an ambulance to bring him in. The doctors said that he had Hydrocephalus, a condition where too much spinal/brain fluid is around his brain. Then they said that the tests over the week showed that he didn't have it, and he just needed physical therapy at Snow Valley to help him walk again. They were pretty vague. He spent the weekend at Snow Valley and started to walk again with the help of a walker, but early on Monday morning he was shaking (like a tree) again and couldn't walk or communicate with anyone.
He was again admitted to Edward and we were told a handful of different problems that he might have. He was brought down to the ICU yesterday and this morning was given a diagnosis. Following this is an email I sent out earlier today describing his condition. Since this email has been sent, he was given an arterial & central line because the PICC line couldn't be put in due to his small veins. I'm going to send you ALL of the emails I've sent out and then at the bottom are some articles about his condition: Serotonin Syndrome.
His doctor recently used the phrases "touch and go" and "critical condition". My mom doesn't seem THAT concerned (I asked her if I should leave work early and she said "not yet") right now, but that's because the doctor said that my dad was touch and go, and is now just critical. It's still scary to hear those words. I know it's a lot to read, so the first part is the latest email, and it goes back from there. If anyone has Ron and or Mary Ellen Durbin's email addresses, can you please send this along? My mom asked me to try to send it, but the email address is at home on a piece of paper, and not in her email account. Please feel free to send this along to anyone else I may have missed. Thank you so much!
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New News:
[April 30, 2008]
Last night my dad was having a really hard time breathing, so they put a mask on him instead of the tube around/under his nose. Because he's been so out of it they haven't been able to give him his inhalers which help with his COPD and emphysema. His breathing became raspy and he looked like he'd just run a marathon; he'd been breathing so hard. So around 11-ish they put a breathing tube in. With the sedative they gave him, his body calmed down almost instantly. That was good to see. It looked like, for the first time in over a week, he was finally sleeping. They purposely, medically paralyzed him in the middle of the night to calm his body down even more because his breathing was still too fast for their liking.
He's been running a fever for a few days, and it turns out that now he has pneumonia. So they're battling that.
He also has a new diagnosis: Serotonin Syndrome. Mike said that it's when psychoactive drugs not reacting with the body well, and causing the body distress. They're giving him an antidote, but Mike didn't have his notes with him so he couldn't tell me the name of the drug. He said that my dad's calm and peaceful.
They did ultra sounds of his legs and showed that there are no blood clots. They also put him on blood thinners to make sure he doesn't obtain any blood clots.
They put a picc line in, and Mike kind of described it as a line that runs from his arm to his heart, and that's supposed to help feed him, although I don't really understand how that works.
[From my new favorite website- http://www.webmd.com/: A central venous catheter, or vascular access device (VAD), is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. PICC line. A peripherally inserted central catheter, or PICC line (say "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest. ]
They called in a cardiologist because of concern for his heart rate, and they did a 2-D echocardiogram and it showed that his heart is not enlarged. Mike said that my dad was much better at 10am than he was at 6.
Mike and my uncle Dave are obviously exhausted, but sound relieved that there's a diagnosis and they know how to treat it. Mike and Dave have already spoken to 4 out of 5 of my dad's doctors.
[April 30, 2008]
Last night my dad was having a really hard time breathing, so they put a mask on him instead of the tube around/under his nose. Because he's been so out of it they haven't been able to give him his inhalers which help with his COPD and emphysema. His breathing became raspy and he looked like he'd just run a marathon; he'd been breathing so hard. So around 11-ish they put a breathing tube in. With the sedative they gave him, his body calmed down almost instantly. That was good to see. It looked like, for the first time in over a week, he was finally sleeping. They purposely, medically paralyzed him in the middle of the night to calm his body down even more because his breathing was still too fast for their liking.
He's been running a fever for a few days, and it turns out that now he has pneumonia. So they're battling that.
He also has a new diagnosis: Serotonin Syndrome. Mike said that it's when psychoactive drugs not reacting with the body well, and causing the body distress. They're giving him an antidote, but Mike didn't have his notes with him so he couldn't tell me the name of the drug. He said that my dad's calm and peaceful.
They did ultra sounds of his legs and showed that there are no blood clots. They also put him on blood thinners to make sure he doesn't obtain any blood clots.
They put a picc line in, and Mike kind of described it as a line that runs from his arm to his heart, and that's supposed to help feed him, although I don't really understand how that works.
[From my new favorite website- http://www.webmd.com/: A central venous catheter, or vascular access device (VAD), is a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products over a long period of time, usually several weeks or more. A catheter is often inserted in the arm or chest through the skin into a large vein. The catheter is threaded through this vein until it reaches a large vein near the heart. PICC line. A peripherally inserted central catheter, or PICC line (say "pick"), is a central venous catheter inserted into a vein in the arm rather than a vein in the neck or chest. ]
They called in a cardiologist because of concern for his heart rate, and they did a 2-D echocardiogram and it showed that his heart is not enlarged. Mike said that my dad was much better at 10am than he was at 6.
Mike and my uncle Dave are obviously exhausted, but sound relieved that there's a diagnosis and they know how to treat it. Mike and Dave have already spoken to 4 out of 5 of my dad's doctors.
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[April 29, 2008]
Gooooood morning! It's about 2:30am here in beautiful Edward Hospital. No real changes with my dad. We're taking turns "sitting" with my dad. He needs a sitter 24/7 so we're taking turns. Amy and I had our turn for awhile and then she woke Mike up and she left. Mike's upstairs with my dad now while I take a break. Surprisingly I'm not sleepy at all. So that's good. I can go back upstairs and help out. My dad hasn't really slept. He got some Valium at 11:05 (i took notes on the nice little pad given to us by the hospital) and it lasted for about half an hour. He got a really good sleep for 15 minutes, kinda woke up and rested for a little longer. Then they gave him some haldol and that didn't really do much. It slowed the tremors a bit, but he's still not sleeping. He's not sure what's going on and when I ask him if he knows where he is he can kind of mumble, "Sure I know" and then when I ask him where he is, he mumbles even more and I just can't figure out what he's saying. He's going to see a few doctors in the morning so hopefully we'll get some answers. Right now, though, I think we're just waiting it out. We were told that he's going through withdrawal from some medicine, but everything has changed within the past few days, so we can't really say for sure what he's withdrawing from.
They have nice cyber centers all around the hospital but I'm not used to this keyboard so I keep making typos. So I'm going to go now. More info later when I get it. Ta ta!
Gooooood morning! It's about 2:30am here in beautiful Edward Hospital. No real changes with my dad. We're taking turns "sitting" with my dad. He needs a sitter 24/7 so we're taking turns. Amy and I had our turn for awhile and then she woke Mike up and she left. Mike's upstairs with my dad now while I take a break. Surprisingly I'm not sleepy at all. So that's good. I can go back upstairs and help out. My dad hasn't really slept. He got some Valium at 11:05 (i took notes on the nice little pad given to us by the hospital) and it lasted for about half an hour. He got a really good sleep for 15 minutes, kinda woke up and rested for a little longer. Then they gave him some haldol and that didn't really do much. It slowed the tremors a bit, but he's still not sleeping. He's not sure what's going on and when I ask him if he knows where he is he can kind of mumble, "Sure I know" and then when I ask him where he is, he mumbles even more and I just can't figure out what he's saying. He's going to see a few doctors in the morning so hopefully we'll get some answers. Right now, though, I think we're just waiting it out. We were told that he's going through withdrawal from some medicine, but everything has changed within the past few days, so we can't really say for sure what he's withdrawing from.
They have nice cyber centers all around the hospital but I'm not used to this keyboard so I keep making typos. So I'm going to go now. More info later when I get it. Ta ta!
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[April 28, 2008]
Hello All!My dad moved from Edward Hospital to Snow Valley Nursing home on Friday night. It's partially good news because he was "too healthy" to go to Marionjoy. (I still haven't learned if it's Marionjoy or Marion Joy or something else, but I guess it doesn't really matter anymore because he's not going there.) He wasn't able to see a physical therapist over the weekend, so Mike and Joe will have an update hopefully today. As of last night we didn't know how long my dad is supposed to be there or what other things we should expect. My dad's walking with a walker, which is great. He doesn't need help walking around and he was able to lower himself into a chair yesterday while his brothers Tim & Dave visited. He needs more help getting out of bed, but I'm sure that will get better with time. My mom was reading her Merck Manual (the book that "transforms the language of the professionals' version into commonly used English while retaining the vital information about diseases, diagnosis,etc"- from the Merck Manual website) last night and in addition to having all of the symptoms of Hydrocephalus, he also has all of the symptoms of advanced kidney disease. So- they're very similar. My dad had already highlighted a lot of the symptoms in the book. Hopefully they'll hear from a doctor soon to answer the many, many questions that have come up over the weekend.
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I wrote that this morning and then got an update from Joe:My dad got a lot worse overnight. He can't walk on his own and is having great difficulty talking. It takes a long time to get words out and when he does, many times it's slurred or mumbled. So they took him by ambulance back to Edward Hospital. The doctor at Snow Valley was very concerned with my dad's quick decline so he sent him back to the hospital. Mike rode with my dad in the ambulance. As far as I know, Joe followed, my mom left work and drove separately, and my uncles Tim, Dave and Kyle are driving over to the hospital. Hopefully doctors at Edward will answer more questions. Joe said that Mike was taking very detailed notes. That's all I have for now.
Hello All!My dad moved from Edward Hospital to Snow Valley Nursing home on Friday night. It's partially good news because he was "too healthy" to go to Marionjoy. (I still haven't learned if it's Marionjoy or Marion Joy or something else, but I guess it doesn't really matter anymore because he's not going there.) He wasn't able to see a physical therapist over the weekend, so Mike and Joe will have an update hopefully today. As of last night we didn't know how long my dad is supposed to be there or what other things we should expect. My dad's walking with a walker, which is great. He doesn't need help walking around and he was able to lower himself into a chair yesterday while his brothers Tim & Dave visited. He needs more help getting out of bed, but I'm sure that will get better with time. My mom was reading her Merck Manual (the book that "transforms the language of the professionals' version into commonly used English while retaining the vital information about diseases, diagnosis,etc"- from the Merck Manual website) last night and in addition to having all of the symptoms of Hydrocephalus, he also has all of the symptoms of advanced kidney disease. So- they're very similar. My dad had already highlighted a lot of the symptoms in the book. Hopefully they'll hear from a doctor soon to answer the many, many questions that have come up over the weekend.
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I wrote that this morning and then got an update from Joe:My dad got a lot worse overnight. He can't walk on his own and is having great difficulty talking. It takes a long time to get words out and when he does, many times it's slurred or mumbled. So they took him by ambulance back to Edward Hospital. The doctor at Snow Valley was very concerned with my dad's quick decline so he sent him back to the hospital. Mike rode with my dad in the ambulance. As far as I know, Joe followed, my mom left work and drove separately, and my uncles Tim, Dave and Kyle are driving over to the hospital. Hopefully doctors at Edward will answer more questions. Joe said that Mike was taking very detailed notes. That's all I have for now.
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[April 25, 2008]
News:
My dad will be released today. He does not have hydrocephalus. His latest test revealed that the fluid around his brain is now at a normal level. He just had problems that were caused by his kidneys. Marionjoy will not accept him because he's not that bad, I guess. So the hospital is calling around to find a place for him to go, because he's not quite ready to go back home. My mom's phone kept cutting out- she was calling from somewhere in the hospital, so I didn't hear where they're trying to place him, which doesn't really matter either way. He'll be going to rehab to strengthen his legs. So that's good. She's not sure what they're going to do about his confusion; maybe that will just clear up with a little more time. She's very thankful that he won't have to get the shunt put in. Yay!
I'll let you know when he's placed somewhere, and what the duration of his stay will be.
Thanks for all of your good thoughts and prayers!
love,
kt
News:
My dad will be released today. He does not have hydrocephalus. His latest test revealed that the fluid around his brain is now at a normal level. He just had problems that were caused by his kidneys. Marionjoy will not accept him because he's not that bad, I guess. So the hospital is calling around to find a place for him to go, because he's not quite ready to go back home. My mom's phone kept cutting out- she was calling from somewhere in the hospital, so I didn't hear where they're trying to place him, which doesn't really matter either way. He'll be going to rehab to strengthen his legs. So that's good. She's not sure what they're going to do about his confusion; maybe that will just clear up with a little more time. She's very thankful that he won't have to get the shunt put in. Yay!
I'll let you know when he's placed somewhere, and what the duration of his stay will be.
Thanks for all of your good thoughts and prayers!
love,
kt
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[April 24, 2008]
Hello All-My dad was very happy to hear that he has so many people saying hi and praying for him and wishing him well. (Side Note: I apologize for having missed some people's emails. I'm not used to sending out emails to so many people on gmail. Comcast has a different system, so I'm still getting used to the gmail format. Andersons- the aol email address I have for Kyle doesn't work. Suggestions? Thanks)My dad seemed much better today. More awake, more chipper. Not a whole lot to report. (I keep saying that and then, suddenly, there is). He went downstairs last night for a 2nd MRI of his shoulder (3rd overall) and it didn't work out. But when I asked why, we were interrupted by a nurse, then Danny, my mom and I went downstairs for dinner and I asked her a ton of other questions, and forgot about the MRI question until just now. He did have a Cisternography: [I got this from the webmd article: This test is much more involved than CT scan or MRI and is not widely used. It highlights absorption of the CSF. (cerebrospinal fluid)]. So they had to insert a needle to inject him with radioactive isotopes and then he had to lie flat for 2 hours. Then they took him downstairs (I keep saying downstairs- I've never been to whatever rooms they keep taking him to- they may be upstairs. Perhaps I've made "downstairs" up in my head. Perhaps they really do go downstairs. Alas, I digress) for 2 other tests, or completions of the cisternography. I'm not sure if it's 3 separate things, or 3 parts of a whole. They had to inject the dye/isotopes/stuff, then view it, and I think view it again. They took him downstairs right as Danny and I were going up to his room to say goodnight. So that timing worked out for us.
I still don't know when the spinal tap is scheduled. I do know that my mom's going back to work tomorrow. Amy and Emma will be visiting my dad tomorrow, as will Danny and I. So I will have MORE ANSWERS! Yay! *happy answers dance*Ok, so this ended up being pretty short. Excellent.Thanks again!
I still don't know when the spinal tap is scheduled. I do know that my mom's going back to work tomorrow. Amy and Emma will be visiting my dad tomorrow, as will Danny and I. So I will have MORE ANSWERS! Yay! *happy answers dance*Ok, so this ended up being pretty short. Excellent.Thanks again!
love,kt
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Recap:
[April 21, 2008]
My dad's staying at Edward Hospital in Naperville. He's got a sketchy diagnosis and a kind of strange problem. On Saturday afternoon, he was shaking a lot and his legs were weak and he was having trouble breathing. By the time he got dressed and ready, and they got to the hospital, his symptoms had subsided, and they figured that it would be kind of a waste of time to go into the hospital if they couldn't show the drs. my dad's problem. They would just see his dr. on Monday morning.Late Saturday night it started again. My uncle John said that my dad was "completely rigid throughout his body, but was shaking the way you would shake a rag doll." He said it was just strange the way his body was stiff, but also shaking a lot at the same time. John has seen people have seizures, and said this was similar (but didn't want to say that he thought my dad had a seizure; just that he needed a way to describe it to us), but my dad was standing upright and his eyes were open and he seemed to be conscious. He was awake, but doesn't really remember any of it now that it's over. He was standing over the stairs and when he tried to move forward or backwards to walk to the car, he couldn't move. So my mom called 911.
The neurologist at Edward said two things: it seems that while my dad was slowly weaning himself off of one anti-depressant (ordered previously by his psychiatrist), it was causing the trembling/shaking. (My mom found some information on that drug and that is one of the "unlikely but possible" side effects) The second thing was that his legs were weak because he was anxious about falling down. This seems like a stretch, because he has this happen from time to time, and then he can walk a few minutes later. It happened when I was out there last weekend. He walked around all day, fine, and then at dinner tried to stand up and his legs almost went out from under him. It was a large effort for him to sit back down again and he hadn't even moved his feet. But then after sitting for awhile he was fine to walk around again. So I'm not sure about the anxiety part. That sounds odd. But, as you all know, I've never been to medical school.I don't really have a good update. His neurologist said that he thought the tremors/severe shaking were from a medicine that he's not taking anymore (as of late Saturday night) and the problem standing/walking is anxiety because he's afraid of falling. I really have a hard time believing that, because he had trouble standing up last weekend, and he walked all day and was fine, then he had trouble, so he sat down for awhile, and then got up and walked around fine. When the neurologist was in my dad's hospital room, he got my dad to stand up and take a few steps. But a couple of hours later when he needed to move from the bed to a chair so close it was almost touching the bed, he couldn't make it on his own. And then when he sat down he was exhausted. Severely winded. He's going to have an MRI sometime this morning but isn't sure what time. Basically I've got a lot of vague answers. But the medicine that he discontinued does have tremors listed as "rare but possible side effects". It's just a concern because it seems that without that medicine he's very irritable and combative. Hopefully it will even out later today. Maybe he'll feel better after he's had breakfast & lunch (I talked to my mom on the phone around 9) and after the MRI.
I'll send more updates later whenever I get them.
[April 21, 2008]
My dad's staying at Edward Hospital in Naperville. He's got a sketchy diagnosis and a kind of strange problem. On Saturday afternoon, he was shaking a lot and his legs were weak and he was having trouble breathing. By the time he got dressed and ready, and they got to the hospital, his symptoms had subsided, and they figured that it would be kind of a waste of time to go into the hospital if they couldn't show the drs. my dad's problem. They would just see his dr. on Monday morning.Late Saturday night it started again. My uncle John said that my dad was "completely rigid throughout his body, but was shaking the way you would shake a rag doll." He said it was just strange the way his body was stiff, but also shaking a lot at the same time. John has seen people have seizures, and said this was similar (but didn't want to say that he thought my dad had a seizure; just that he needed a way to describe it to us), but my dad was standing upright and his eyes were open and he seemed to be conscious. He was awake, but doesn't really remember any of it now that it's over. He was standing over the stairs and when he tried to move forward or backwards to walk to the car, he couldn't move. So my mom called 911.
The neurologist at Edward said two things: it seems that while my dad was slowly weaning himself off of one anti-depressant (ordered previously by his psychiatrist), it was causing the trembling/shaking. (My mom found some information on that drug and that is one of the "unlikely but possible" side effects) The second thing was that his legs were weak because he was anxious about falling down. This seems like a stretch, because he has this happen from time to time, and then he can walk a few minutes later. It happened when I was out there last weekend. He walked around all day, fine, and then at dinner tried to stand up and his legs almost went out from under him. It was a large effort for him to sit back down again and he hadn't even moved his feet. But then after sitting for awhile he was fine to walk around again. So I'm not sure about the anxiety part. That sounds odd. But, as you all know, I've never been to medical school.I don't really have a good update. His neurologist said that he thought the tremors/severe shaking were from a medicine that he's not taking anymore (as of late Saturday night) and the problem standing/walking is anxiety because he's afraid of falling. I really have a hard time believing that, because he had trouble standing up last weekend, and he walked all day and was fine, then he had trouble, so he sat down for awhile, and then got up and walked around fine. When the neurologist was in my dad's hospital room, he got my dad to stand up and take a few steps. But a couple of hours later when he needed to move from the bed to a chair so close it was almost touching the bed, he couldn't make it on his own. And then when he sat down he was exhausted. Severely winded. He's going to have an MRI sometime this morning but isn't sure what time. Basically I've got a lot of vague answers. But the medicine that he discontinued does have tremors listed as "rare but possible side effects". It's just a concern because it seems that without that medicine he's very irritable and combative. Hopefully it will even out later today. Maybe he'll feel better after he's had breakfast & lunch (I talked to my mom on the phone around 9) and after the MRI.
I'll send more updates later whenever I get them.
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Newer update:I just called the hospital (first my dad's room, then my mom's cell) and my dad got up last night to go to the bathroom (BY HIMSELF) and fell and hurt his shoulder. Many nurses were able to come to his aid quickly to help him up. He hasn't gotten up and walked around since. They were both very quick on the phone so I didn't get a LOT of details. He's already had the MRI of his brain, and they're going to do an MRI of his shoulder later today. He's had a bad shoulder for a long time, and I'm not sure if this is the same one, or the other one.When I spoke with my mom, she said that there was an occupational therapist there right now, and a physical therapist will be there later today to check him out. His kidney doctor said today that he's seen these reactions to this medication (I can't remember the name, I'm 99% sure it's Celexa.) in other kidney patients. That's good. Second opinions are always good. My mom's still not sure about the weakness in his legs. She said she'd call me later with updates. It sounded like it was really busy in his hospital room, so they didn't want to stay on the phone long.
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Ok, so as it turns out the MRI showed that my dad has Hydrocephalus. You can click on that link and it goes to webmd.com. The article is about "Normal Pressure Hydrocephalus", but my mom didn't give me anything besides the word hydrocephalus, so I'm not sure if it's normal or not. Hopefully the more I type hydrocephalus, the easier it will be for me to remember how to spell it. Anyway, it occurs when there is too much spinal fluid around the brain. It has these really interesting symptoms that my dad also has:
Dementia symptoms* Memory loss* Speech problems* Apathy (indifference) and withdrawal* Changes in behavior or mood* Difficulties with reasoning, paying attention, or judgmentWalking problems* Unsteadiness* Leg weakness* Sudden falls* Shuffling steps* Difficulty taking the first step, as if feet were stuck to the floor* "Getting stuck" or "freezing" while walkingSo that's pretty good- it's a serious condition, but he's going to have a spinal tap at some point. My mom wasn't sure when. I think she was saying that the hydrocephalus was brought on by use of the Celexa in conjunction with other meds and his kidney disease...I'm not sure. That looks strange now that I've typed it out, but she was given a lot of information in a short amount of time, and I didn't write everything down that she said, so I may have mixed things up. I'm sure about the hydrocephalus, though. It would be nice if they would have it all written out for her, but it didn't happen that way.After he fell and hurt his shoulder, they tried to adjust him to get him to fit into the MRI machine, and they yanked on his shoulder again, which made him really, really angry. He apparently chewed out his nurse (she didn't do it, but he needed someone to yell at), and she totally took it in stride. I'm glad they put her with him. He went through the first MRI fine. He was upset about his shoulder hurting, but was able to get some pain medicine and calmed down. When Danny and I got to the hospital this evening, he was out of his room- downstairs getting an MRI of his shoulder. It didn't work. He had gotten very upset about just being in the MRI machine and worked himself into a sweat and "didn't fit" so they brought him back upstairs to his room. The technician said that she could see that he was in a lot of pain. His nurse asked him how he fit into the MRI machine the first time. He swore up and down that this was a different machine, different size, blah blah blah. Edward hospital has 2 machines and they're exactly the same and they're in the same area, just separated by an office. He wasn't sure. Then he couldn't remember actually going into the MRI. He remembered telling my mom that he liked the ping-ing noise that the machine makes, but didn't remember actually lying down for the test. The nurse talked him into going to do the MRI for his shoulder a second time around 7:30. She said that she'd give him drugs at 8, and they'd come to pick him up at 8:30 and he'd be fine, so he agreed. Danny and I left around 8, and my mom left a little while later, and doesn't know how the MRI went. I just called my dad's room and there's no answer, so either he's still doing the MRI, or he's asleep.
When he's done with his stay at Edward, (and they don't know when that will be) he will be staying at another facility for rehab-learning to walk and for his shoulder, and some other things. My mom's not sure how long he'll be there, either. Hopefully they'll have some more concrete answers tomorrow. My mom needed to get some sleep and she'll be back to the hospital tomorrow. She took a LOT of time off of work last month when she was in the hospital with pneumonia, so cross your fingers that her boss doesn't give her crap for taking more time off. I don't think they will, but extra good luck fingers couldn't hurt. I'm glad he's in the hospital now when many of his symptoms are visible so the doctors can help. It's a lot easier than my mom just telling a doctor that he's got a poor memory. He calls me Sheila a lot, but usually corrects himself right away, but he didn't correct himself today. Then he didn't remember the MRI, and some other things that happened throughout the day. I have a good feeling that this will work out well for him, and my mom seems upbeat, just kind of confused and overloaded with information. At least now we have some things straightened out.I know there are a lot of holes in this, but hopefully I'll get everything filled in soon.
Dementia symptoms* Memory loss* Speech problems* Apathy (indifference) and withdrawal* Changes in behavior or mood* Difficulties with reasoning, paying attention, or judgmentWalking problems* Unsteadiness* Leg weakness* Sudden falls* Shuffling steps* Difficulty taking the first step, as if feet were stuck to the floor* "Getting stuck" or "freezing" while walkingSo that's pretty good- it's a serious condition, but he's going to have a spinal tap at some point. My mom wasn't sure when. I think she was saying that the hydrocephalus was brought on by use of the Celexa in conjunction with other meds and his kidney disease...I'm not sure. That looks strange now that I've typed it out, but she was given a lot of information in a short amount of time, and I didn't write everything down that she said, so I may have mixed things up. I'm sure about the hydrocephalus, though. It would be nice if they would have it all written out for her, but it didn't happen that way.After he fell and hurt his shoulder, they tried to adjust him to get him to fit into the MRI machine, and they yanked on his shoulder again, which made him really, really angry. He apparently chewed out his nurse (she didn't do it, but he needed someone to yell at), and she totally took it in stride. I'm glad they put her with him. He went through the first MRI fine. He was upset about his shoulder hurting, but was able to get some pain medicine and calmed down. When Danny and I got to the hospital this evening, he was out of his room- downstairs getting an MRI of his shoulder. It didn't work. He had gotten very upset about just being in the MRI machine and worked himself into a sweat and "didn't fit" so they brought him back upstairs to his room. The technician said that she could see that he was in a lot of pain. His nurse asked him how he fit into the MRI machine the first time. He swore up and down that this was a different machine, different size, blah blah blah. Edward hospital has 2 machines and they're exactly the same and they're in the same area, just separated by an office. He wasn't sure. Then he couldn't remember actually going into the MRI. He remembered telling my mom that he liked the ping-ing noise that the machine makes, but didn't remember actually lying down for the test. The nurse talked him into going to do the MRI for his shoulder a second time around 7:30. She said that she'd give him drugs at 8, and they'd come to pick him up at 8:30 and he'd be fine, so he agreed. Danny and I left around 8, and my mom left a little while later, and doesn't know how the MRI went. I just called my dad's room and there's no answer, so either he's still doing the MRI, or he's asleep.
When he's done with his stay at Edward, (and they don't know when that will be) he will be staying at another facility for rehab-learning to walk and for his shoulder, and some other things. My mom's not sure how long he'll be there, either. Hopefully they'll have some more concrete answers tomorrow. My mom needed to get some sleep and she'll be back to the hospital tomorrow. She took a LOT of time off of work last month when she was in the hospital with pneumonia, so cross your fingers that her boss doesn't give her crap for taking more time off. I don't think they will, but extra good luck fingers couldn't hurt. I'm glad he's in the hospital now when many of his symptoms are visible so the doctors can help. It's a lot easier than my mom just telling a doctor that he's got a poor memory. He calls me Sheila a lot, but usually corrects himself right away, but he didn't correct himself today. Then he didn't remember the MRI, and some other things that happened throughout the day. I have a good feeling that this will work out well for him, and my mom seems upbeat, just kind of confused and overloaded with information. At least now we have some things straightened out.I know there are a lot of holes in this, but hopefully I'll get everything filled in soon.
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This is from a blog on webmd:
This article is very good as well. It has a bit more clinical information related recognition and management. It contains lists of specific drugs to be aware of. It also includes some case studies and differential diagnosis information I think might be interesting and helpful. If you find you are taking any medications or have any concerns about your medication regimen, I encourage you to talk to your physician promptly and discuss appropriate alternatives.
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"This Article" as referenced in the above blog is here. It's really long and I haven't read even half of it, but here it is.
Serotonin Syndrome: Recognition and Management
http://www.uspharmacist.com/oldformat.asp?url=newlook/files/feat/acf2fa6.htm
Steve Nolan, Pharm.D. Resident, University of Tennesesee College of Phamacy and William F. Bowld Hospital, Memphis J. Allen Scoggin, Pharm.D., MPA Associate Professor of Pharmacy Practice and Pharmcoeconomics, University of Tennessee College of Pharmacy, Memph
Serotonin syndrome is described in the literature as a potentially serious drug-related condition characterized by a number of mental, autonomic and neuromuscular changes.1 Although serotonin syndrome can cause death, the condition is mild in most persons, and with supportive care alone they tend to recover completely. The syndrome, first described in animal models in the 1950s, was referred to as the "serotonin behavioral" or "hyperactivity syndrome."1
Reports of serotonin syndrome in humans followed, and have become increasingly frequent since the 1960s. The earliest reports involved persons who were taking monoamine oxidase inhibitors (MAOIs). Some of the early reports included patients who were also taking tryptophan, a serotonin precursor.1,2
Serotonin syndrome is most often reported in patients taking two or more medications that increase CNS serotonin levels by different mechanisms. The most common drug combinations associated with serotonin syndrome involve the MAOIs, selective serotonin reuptake inhibitors (SSRIs), and the tricyclic antidepressants.3 Because of the dramatic rise in the use of SSRIs, it is predicted that emergency room physicians are going to encounter the serotonin syndrome more frequently than in the past.1 Symptoms associated with the condition appear in TABLE 1.
Symptoms Associated with Serotonin Syndrome
Mental status changesConfusion (51%)Agitation (34%)Hypomania (21%)Anxiety (15%)Coma (29%)
CardiovascularSinus tachycardia (36%)Hypertension (35%)Hypotension (15%)
GastrointestinalNausea (23%)Diarrhea (8%)Abdominal pain (4%)Salivation (2%)
References 2, 4
Motor AbnormalitiesMyoclonus (58%)Hyperreflexia (52%)Muscle rigidity (51%)Restlessness (48%)Tremor (43%)Ataxia/incoordination (40%)Shivering (26%)Nystagmus (15%)Seizures (12%)
OtherDiaphoresis (45%)Unreactive pupils (20%)Tachypnea (26%)Hyperpyrexia (45%)
Several other medications can precipitate the serotonin syndrome (TABLE 2). Increased reporting of cases appears to be related to at least three things: recently published diagnostic criteria describing serotonin syndrome; greater use of antidepressant medications, such as the SSRIs; and an increased attempt by physicians to differentiate serotonin syndrome from neuroleptic malignant syndrome.4
TABLE 2.
Drugs that Affect Serotonin Levels
Effect
Drug
Increase serotonin synthesis
L-tryptophan
Decrease serotonin metabolism
isocarboxazidphenelzineselegilinetranylcypromine
Increase serotonin release
amphetaminescocainereserpine
Inhibit serotonin uptake
amitriptylineclomipraminedesipraminedoxepinimipraminenortriptylineprotriptylinefluvoxaminefluoxetineparoxetinenefazadonesertralinetrazodoneamphetaminescocainedextromethorphanmeperidinevenlafaxine
Direct serotoninreceptor agonists
buspironelysergic acid diethylamide(LSD)sumatriptan
Nonspecific increase inserotonin activity
lithium
Dopamine agonists
amantadinebromocriptinebupropionlevodopapergolidepramipexole
References 2, 4
Mild to moderately severe cases of serotonin syndrome usually resolve in 24 to 72 hours.1 Though most cases can be treated and resolve within a week, some patients become acutely ill and require hospitalization. In some instances patients have been admitted to the ICU and required mechanical ventilation. Mortality associated with this condition is estimated to be 11%.4
Serotonin Receptors
Serotonin (5-HT; 5-hydroxytryptamine) occurs naturally in the body. In the periphery, serotonin acts both as a gastrointestinal regulating agent and a modulator of blood vessel tone.5 Although only 2% of the body's serotonin is found in the brain as a neurotransmitter, the chemical can have a profound effect on body functions. As a neurotransmitter, serotonin is involved in the modulation of motor function, pain perception, appetite, and outflow from the sympathetic nervous system.4
Serotonin acts at receptors generally classified into one of four categories, depending upon function and location. The four recognized serotonin receptors identified are 5-HT1, 5-HT2, 5-HT3 and 5-HT4. Receptor subtypes also have been identified. For example, the 5-HT1d subtype lies outside the CNS and is the receptor through which sumatriptan exerts its antimigraine effect. Researchers agree that the majority of signs and symptoms associated with serotonin syndrome involve excessive stimulation of the 5-HT
1A receptor.1,6 Recent studies, however, show that the 5-HT2 receptor may be at least partially responsible for the serotonin syndrome.1,4 The 5-HT2 receptors are located in the brain and peripheral blood vessels.
Most cerebral functions are the result of the convergence of many different neurotransmitters, including serotonin.7 This complex network of neurotransmitters makes it possible for serotonin to affect many functions and actions of the brain. For example, serotonin often serves as a cotransmitter along with gamma-aminobutyric acid (GABA) and norepinephrine. Serotonin antagonizes GABAB receptors, causing upregulation of this subtype. The activity of benzodiazepines in the treatment of serotonin syndrome is thought to occur because these compounds act as strong agonists at GABAB receptors. Certain dopaminergic neurons have serotonin receptors, resulting in serotonin-modulated release of dopamine in different areas of the brain.
Serotonin Syndrome Risk Factors
Risk factors for the development of serotonin syndrome are unclear, but some trends are becoming apparent as more cases appear in the literature. Some researchers have suggested that peripheral vascular disease and atherosclerosis may lead to severe vasospasm and hypertension in the presence of elevated serotonin levels. This seems paradoxical, since in peripheral areas of the body serotonin usually causes vasodilation. However, in patients with vascular disease serotonin can lead to profound vasoconstriction.6
Another risk factor relates to drug metabolism rate. Slow metabolizers of SSRIs (approximately 7% of the population) may produce higher than normal levels of these antidepressants in the blood. A slow metabolizer receiving an SSRI in combination with another agent that raises serotonin levels is therefore at increased risk of developing serotonin syndrome.
6
Clinical Features and Differential Diagnosis
Mental status changes are the most frequently reported symptoms associated with serotonin syndrome.2 Other commonly reported features include motor abnormalities, cardiovascular changes, gastrointestinal problems and miscellaneous changes such as diaphoresis and fever (TABLE 1).2,4 Martin refers to three categories of symptoms that are present: altered mental status, autonomic dysfunction and neuromuscular abnormalities.1 Sporer indicates that at least three of the following must be present for a diagnosis: mental status changes, agitation, myoclonus, hyperreflexia, fever (hyperpyrexia), shivering, diaphoresis, ataxia and diarrhea in the setting of a recent addition or increase in dose of an agent that raises serotonin levels. Sporer also points out that there should be no other obvious causes of the confusion and/or fever, and that no antipsychotic medications have been used or increased in dose prior to the onset of symptoms.3
Poisonings and other diseases, such as neuroleptic malignant syndrome (NMS), can cause symptoms that are very similar to serotonin syndrome (TABLE 3). Martin offers suggestions that may be useful in differentiating serotonin syndrome from these conditions. One is an observation that bromocriptine has been proposed as a treatment for NMS and a cause or precipitant of serotonin syndrome. Another is that NMS occurs from prolonged exposure to neuroleptic agents or withdrawal of dopamine agonists, and there is lead-pipe rigidity with NMS, in contrast to myoclonus or hyperreflexia seen in persons with serotonin syndrome.1
TABLE 3.
Differential Diagnosis of Serotonin Syndrome
Diseases
Poisonings
Catatonia
Anticholinergics
Dystonia reaction (severe)
Amphetamines
Encephalitis
Cocaine
Hyperthyroidism
2,4 dichlorophenoxyacetic acid
Malignant hyperthermia
Dinitrophenol
Meningitis
Lithium
Neuroleptic malignant syndrome
LSD
Septicemia
MAOIs
Stiff-man syndrome
Pentachlorophenol
Tetanus
PCP (phencyclidine)SalicylatesStrychnine Water hemlock
Reference 1
Medications Linked with Serotonin Syndrome
Causative agents associated with serotonin syndrome include those that: increase serotonin synthesis (L-tryptophan); decrease serotonin metabolism (MAOIs); increase serotonin release; inhibit serotonin uptake (SSRIs); and stimulate certain serotonin receptors directly, and provide a nonspecific increase in serotonin activity (TABLE 2).
The largest number of cases reported in the literature and the most serious consequences of serotonin syndrome have resulted from use of the MAOIs.3 Most cases were reported when an MAOI was used in conjunction with meperidine, tryptophan, dextromethorphan (an ingredient in many over-the-counter products), a tricyclic antidepressant, or an SSRI antidepressant.2,3 The long half-life (SSRIs) and duration of effect (irreversible MAOIs) seen with some of these medications increase the possibility of serotonin syndrome occurring several weeks after these drugs have been discontinued.1 It is important to note that serotonin syndrome has been precipitated by medications that are not usually thought of as being serotonergic. One author asserts that both meperidine and dextromethorphan are "notorious for precipitating acute serotonin syndrome."4
Case Reports
Select cases of suspected or confirmed serotonin syndrome illustrate the broad range of circumstances in which this condition can occur. Although there are many reports of "possible" serotonin syndrome reactions in the literature, in many instances the syndrome is not fully developed as there may be question as to whether the symptoms reported are really the result of serotonin syndrome. In such instances the diagnostic criteria developed by Sternbach, Martin and Sporer should be followed.1-3
Case No. 1:A case reported in 1994 involved a 48-year-old man brought to the emergency room due to agitation and confusion. He had a three-year history of depression which was being treated with tranylcypromine (Parnate), an MAOI. The tranylcypromine was discontinued prior to E.R. presentation. Fourteen days after the MAOI was discontinued, fluoxetine (40 mg daily) was begun. Over the next 72 hours the patient developed agitation, diaphoresis and confusion. During his hospital stay he developed tachycardia and profound muscle rigidity and had to be intubated. In addition to supportive measures, the patient received diazepam and propranolol to relieve muscle rigidity, hypertension and tachycardia. By the third hospital day his temperature returned to normal and he rapidly recovered. He was released on the fifth day.
8
This case underlines the extreme importance of implementing a "wash out" period after the discontinuation of one serotonergic drug before the implementation of another. Even after two weeks, the effect of tranylcypromine was still active enough to cause a serotonergic crisis when therapy with fluoxetine was begun.
Case No. 2: A 72-year-old man was admitted to the hospital for presumed Parkinson's disease and depression. He was placed on selegiline and fluoxetine. After nine weeks of treatment, he presented with acute delirium which progressed to lethargy, malaise, myoclonic jerking and grand mal seizures. The fluoxetine was discontinued, but seven days later he experienced acute delirium, convulsions, and became unresponsive. The selegiline was discontinued. Five days later symptoms resolved completely.9 This case demonstrates the ability of fluoxetine to exert its serotonergic effects for a few days up to weeks after discontinuation. The effect probably is due to the long half-life of both fluoxetine and its active metabolite, norfluoxetine.
Case No. 3: A recent report describes a 51-year-old man who developed serotonin syndrome when he combined Nyquil with paroxetine (Paxil). Pertinent medical history included depression, for which he was taking paroxetine, and peripheral vascular disease. Four days prior to admission, he developed nasal congestion which he self-medicated with Nyquil. Two days later, he experienced nausea, extreme shortness of breath, and confusion. Upon admission to the hospital he was experiencing tachycardia and his blood pressure was 202/110. During hospitalization the patient became rigid and more confused. Potential causes of symptoms, including strychnine poisoning, anxiolytic withdrawal and tetanus were ruled out (
TABLE 3). Administration of lorazepam resolved all symptoms, and he was transferred to the ICU with normal mental status. The paroxetine was discontinued, and after a four-week follow-up, the patient remained asymptomatic.5
The most probable explanation for the development of serotonin syndrome in this patient was the combination of dextromethorphan (an ingredient in Nyquil) and paroxetine. The pseudoephedrine in Nyquil (10 mg/5 mL) may have produced the adrenergic effect (e.g., increased blood pressure). In addition, the vascular disease may have been a predisposing factor. Dextromethorphan inhibits reuptake of serotonin (TABLE 2) and has previously been implicated in serotonin syndrome when combined with an MAOI.4,5 It has been shown that persons with a history of vascular endothelial damage are at risk of vasospasm in the presence of increased serotonin levels.1 The authors of this case report suggest that patients with pre-existing vascular disease may be at increased risk of developing complications related to increased serotonin levels. As a result, caution should be exercised when administering serotonergic medications to patients with vascular disease. If possible, such patients should consult a physician or pharmacist before self-medicating with over-the-counter cough medicines.
Case No. 4:The newer antidepressants may pose a potential problem as well. For example, nefazodone (Serzone), blocks 5-HT2 receptors and also inhibits reuptake of serotonin. Recently there was a report of a 51-year-old woman with a history of bipolar disorder who was brought to the emergency room unresponsive, diaphoretic, hyponatremic and with muscle rigidity. The patient had taken nefazodone (Serzone) for six months and had just discontinued the drug for two days. One day before admission she was started on paroxetine (Paxil). She improved dramatically after supportive treatment and dantrolene.
10 Although nefazodone is a relatively weak 5-HT reuptake inhibitor, it is still capable of causing serotonin syndrome when combined with a stronger 5-HT reuptake inhibitor. While the researchers who reported this case believe it to be the first case of serotonin syndrome reported from the use of nefazodone and paroxetine, they point to other reports involving the use of trazodone and paroxetine.
TABLE 4.
Pharmacist Management of Serotonin Syndrome
Patient/Prescriber Education
Make certain patients understand potential problems, what they should look for, and what to do if symptoms occur (e.g., muscle spasms, shaking, shivering, sweating, confusion)
Contact prescribers when the risk for serotonin syndrome increases (e.g., concurrent therapy with two or more serotonergic agents). Counsel patients to determine if OTC products containing serotonergic ingredients are being used.
Prevention
Reconsider using two or more serotonergic medications
Consider switching to less serotonergic alternatives
Management
Discontinue all serotonergic medications
Consider benzodiazepines for myoclonus and resultant hyperthermia
Consider cyproheptadine, propranolol, or methysergide if symptoms persist
Provide immediate supportive care as necessary (e.g., therapy for hypertension, tachycardia, hyperthermia, respiratory distress)
No specific therapeutic approach to the treatment of serotonin syndrome has been fully evaluated in the literature. The most common treatment involves the use of the benzodiazepines. In severe cases, the antiserotonergic agents cyproheptadine, methysergide, and propranolol have been used.3,6,11 In all cases the suspected agent should be discontinued. Over-the-counter drugs containing ingredients known to increase serotonin levels or exacerbate the patient's condition, such as dextromethorphan, pseudoephedrine or phenylpropanolamine, also should be discontinued.
Initial treatment should consist of supportive measures aimed at reducing hypertension, tachycardia, hyperthermia and respiratory distress if these conditions are present. Lorazepam and diazepam have been shown to be effective in treating myoclonus associated with serotonin syndrome, and in mild cases, are usually the only treatment necessary. It is important to note that clonazepam has been found to be ineffective in treating serotonin syndrome. Unlike diazepam and lorazepam, clonazepam is not a potent agonist of the GABAB receptor.6 The more severe cases that do not respond to benzodiazepines may respond to dantrolene, which may be effective in relieving muscle rigidity and hyperthermia.
1
Pharmacists should recognize potential problems associated with the concurrent use of certain medications, such as the MAOIs and the SSRIs and other agents that can cause serotonin syndrome. Due to the potentially serious nature of this condition, it seems prudent that pharmacists always monitor patients who are taking combinations of serotonergic drugs and be alert to the possibility of "serotonergic duplication" and notify physicians and other prescribers when the risk of drug adversity appears eminent. The use of therapeutic alternatives in certain instances could be life-saving.
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