Hemorrhage in Long-term Ventilated Critically ill Patients Treated with Citalopram: Report of Four Cases

Summary: Depression is a common finding among patients undergoing long-term ventilation in ICU. Therefore, the use of antidepressants in these critically ill patients is advised. Due to the multiple adverse effects of classic tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRI) have become first line agents in treatment of clinical depression. However, multiple case reports and uncontrolled studies suggest that the use of SSRI is associated with an increased bleeding risk. Platelet dysfunction due to serotonin reuptake inhibition in platelets is regarded as an explanation for this adverse effect.

Case reports: We present four cases of long-term ventilated patients in an ICU with hemorrhage during antidepressant treatment with citalopram. Two patients showed symptoms of subcutaneous bleedings, petechiae, epistaxis and prolonged bleeding following minor skin lesions. These symptoms decreased upon ending the treatment with citalopram. Two patients developed pulmonary bleedings, followed by a severe decline in pulmonary function. One patient died of fatal pulmonary hemorrhage. The other patient received daily thrombocyte-transfusions and bronchoscopies for several weeks, followed by a full recovery of pulmonary function.

As all patients suffered from a severe renal insufficiency and two patients showed episodes of hemorrhage prior to the treatment with citalopram, the relevance of citalopram administration in these cases is uncertain.

Conclusion: The use of citalopram in long-term ventilated patients bears the risk of hemorrhage. However, multiple factors in critically ill patients lead to an increased disposition for bleeding events. Further investigation of the coincidence of SSRI treatment and hemorrhage is advised. This should include monitoring of citalopram blood concentration and platelet function tests.