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Table 2 Timeline of development of symptoms and management

From: Serotonin syndrome triggered by postoperative administration of serotonin noradrenaline reuptake inhibitor (SNRI)

Time Symptoms Management
Day 1 8:33 a.m. After taking SNRI, hot flush, stiffness around the neck and shoulder, diaphoresis, and muscle rigidity in the masseter appeared. BP 112/78 mmHg, 77 bpm, BT 37.4 °C Body cooling Intravenous administration of dantrolene 40 mg for muscle rigidity. No abnormalities were found in the blood test.
   10:10 No raise in serum serotonin level (4 ng/ml) Diagnosed as serotonin syndrome Serotonergic agents (duloxetine and mirtazapine) were stopped immediately.
   12:45 Myoclonus and tremor on the upper extremities. Tachycardia (120 bpm) and diaphoresis  
   13:00 Myoclonic seizures on the upper extremities and neck. Tachycardia (140 bpm), BP 162/102 mmHg, respiratory rate 28/min  
   13:20 Myoclonic seizures on the shoulders and neck. Tachycardia (140 bpm), BP 169/120 mmHg, respiratory rate 35/min Admitted to the intensive care unit. Clonazepam 1.0 mg (per oral), intralipid (20%) 100 ml, and started landiolol 0.01 mg/kg/min
   16:10 No myoclonus was seen after the initial dose of cyproheptadine. Vital was stabilized soon. Cyproheptadine 12 mg (per oral)
   22:00   Cyproheptadine 4 mg (per oral)
Day 2 6:00   Cyproheptadine 4 mg (per oral) Moved to general ward
Day 4   Discharged from the hospital