morbidity and mortality report micu bliss 11i veena panduranga juliana alvarez-argote
TRANSCRIPT
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Morbidity and Mortality report
MICU Bliss 11I
Veena Panduranga
Juliana Alvarez-Argote
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Neuroleptic malignant syndrome
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Learning Objectives
Describe a case of neuroleptic malignant syndrome
Review the pathophysiology, diagnosis, and management of neuroleptic malignant syndrome
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Overview
Life-threatening, idiosyncratic reaction to medications affecting central dopaminergic neurotransmission.
Early recognition is critical to prevent morbidity and death
First reported case in 1956 with chlorpromazine
Berman. Neurohospitalist. 2011 January
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Overview
Dopamine depletion Dopamine receptor blockers:
Virtually all antipsychotics, including atypical antipsychotics
Cessation of dopaminergic medications: levodopa, amantadine, tolcapone
Incidence: 0.02% to 2% of pts on neuroleptics
Adnet et al. Br J Anaest. 2000
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Medications associated with NMS
Berman. Neurohospitalist. 2011 January
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Pathophysiology
Strawn et al. Am J Psychiatry 164:6, June 2007
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Clinical presentation
Within 2 weeks after exposure Most cases hours to days after exposure Muscular rigidity followed by hyperthermia in several
hours, along with wide range of altered mental status Drowsiness, agitation, confusion, delirium, coma
Autonomic dysfunction: labile BP, tachypnea, tachycardia, sialorrhea, diaphoresis, flushing, skin pallor, incontinence
Berman. Neurohospitalist. 2011 January
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Lab findings
High CK (rhabdomyolysis) Leukocytosis Iron deficiency (96%) Renal failure (from
rhabdomyolysis) Metabolic acidosis EEG: non generalized slowing
Berman. Neurohospitalist. 2011 January
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Diagnosis: DSM IV criteria:
Muscular rigidity (96%) T>100,4 Use of neuroleptic
medication
Two or more of: Diaphoresis Dysphagia Tremor Incontinence (54%) AMS Mutism (96%) Tachycardia Labile BP (40%) Leukocytosis Elevated CK (91%)
Symptoms not explained by another substance or medical condition
Perry and Wilborn. Ann Clin Psychiatry. 2012
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Diagnosis
DSM IV criteria: Severe muscular rigidity and high temperature,
associated with use of neuroleptic medication Two or more of: diaphoresis, dysphagia, tremor,
incontinence, AMS, mutism, tachycardia, labile BP, leukocytosis, elevated CK
Symptoms not explained by another substance or medical condition
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Differential diagnosis Heat stroke:
flaccid extremities, abrupt onset, hypotension, dry skin CNS infection:
Prodrome symptoms, meningismus, CSF labs Serotoninergic sd.
Absence of high CK, leukocytosis, presence of GI symptoms (n/v/d) Lethal catatonia:
Psychosis for weeks prior to presentation Malignant hyperthermia:
History of depolarizing muscle relaxants or inhaled anesthetics Cocaine intoxication Alcohol w/d
Strawn et al. Am J Psychiatry. 2007
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Management Neurologic emergency
Many will need ICU level of care Stop neuroleptic Restart dopaminergic meds in withdrawal
(levodopa) Aggressive hydration (if high CK, AKI) Control temperature Bicarb for AKI Cardio respiratory support
Adnet et al. Br J Anaest. 2000Reulbach et al. Critical Care 2007
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Management Bromocriptine: dopaminergic
PO or NGT 2.5mg BID or TID increase up to 45mg/d Monitor liver function
Benzodiazepines: Reasonable first line 1-2mg IV/IM q 4-6h Mild/moderate cases or primarily catatonic symptoms
Strawn et al. Am J Psychiatry. 2007Reulbach et al. Critical Care. 2007
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Management Amantadine: anticholinergic
100mg PO/NGT q 8h Moderate cases
Dantrolene: muscle relaxant, inhibits calcium release from sarcoplasmic reticulum Severe cases (T >104, HR >120) 2.5mg/Kg + 1mg/Kg q 6h IV Increase up to 10mg/Kg/d Stop once symptoms resolving (resp
failure/hepatotoxicity) ECT:
Cases with no response to medications/supportive care
Strawn et al. Am J Psychiatry. 2007Reulbach et al. Critical Care. 2007
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Complications
Renal failure DIC Rhabdomyolysis MI Asp. PNA Seizures, arrhythmias (lyte abnormalities)
Reulbach et al. Critical Care 2007
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When to restart neuroleptics
Wait 2 weeks for PO antipsychotics Wait 5 weeks for depot forms Change neuroleptic med Switch from typical to atypical Start at low doses, titrate slowly
Neuroleptic Malignant Syndrome Information Service. 2011. http://www.nmsis.org
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Prognosis
Mortality ~40% before 1984 Mortality greatly reduced (~10%) when recognized
and treated early
Recurrence of NMS in 30-50% cases after restarting neuroleptics
Complete recovery in first 2 days to 2 weeks Mortality 2/2 arrhythmia, DIC, renal or CV
complications
Bottoni. Hospital physician. 2002
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Take home points… NMS is a rare but severe reaction to dopamine blocking agents or
withdrawal to dopaminergic agents Early recognition is critical in preventing significant morbidity and
mortality Main manifestations are muscular rigidity, hyperthermia and
history of medication intake or abrupt cessation Main management consists of stopping offending agent/restarting
dopaminergic, aggressive hydration and temperature control Medications for NMS treatment include benzos, dantrolene, Many will require ICU level 2/2 cardiorespiratory decompensation
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Thank you!