The use of clonidine in the management of autonomic overactivity in neuroleptic malignant syndrome

A systematic review of sex and age factors in neuroleptic malignant syndrome diagnosis frequency

OBJECTIVE

To examine sex and age distributions in neuroleptic malignant syndrome (NMS) patients based on a systematic literature review.

METHOD

EMBASE and PubMed databases were searched to identify any observation of NMS published from January 1, 1998 through November 1, 2014 that was accessible and interpretable (using language translation software). Redundant and equivocal reports were excluded. Sex ratio and age distributions were examined using standard graphical techniques and measures of association.

RESULTS

Twenty-eight independent sex ratio estimates were included. Males predominated in most (75%) estimates with an overall median sex ratio of 1.47 (95% CI, 1.20-1.80). NMS incidence peaked at age 20-25 years and declined steadily thereafter, with males consistently outnumbering females at all but the oldest age intervals.

CONCLUSION

NMS patients are 50% more likely to be males, and NMS is most likely to occur in young adulthood.

Neuroleptic malignant syndrome in trauma patient

In recent years, there has been an increased use of neuroleptic agents in the unit care in trauma patients. There is a lack of prospective data, and most of the information is obtained from related cases. It is needed to have a high index of suspicion with regard to excluding neuroleptic malignant syndrome (NMS) in patients taking neuroleptics and presenting with hyperthermia, because of the potentially fatal consequences. It is a rare syndrome in the burn patient with a lack of proven treatments, and high morbidity and mortality are related. In the actual literature there are few related cases of NMS in the polytrauma patient, particularly in association with psychiatric conditions. In burn NMS is a rare complication with difficult diagnosis, because of the similar symptoms that can occur either in patients in the Burn Unit Care with other fatal conditions that are present in the acute phase response. Actually, there is no marker for the NMS, which difficult the early diagnosis and prognosis. The treatment still is based on case reports, with lack of clinical trials, but remain as standard and universally accepted. Besides that, the neural signaling of the NMS indicates possibilities for better understanding of the pathophysiology treatment protocol.

Neuroleptic malignant syndrome: a review for neurohospitalists

Neuroleptic malignant syndrome (NMS) is a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. It has been associated with virtually all neuroleptics, including newer atypical antipsychotics, as well as a variety of other medications that affect central dopaminergic neurotransmission. Although uncommon, NMS remains a critical consideration in the differential diagnosis of patients presenting with fever and mental status changes because it requires prompt recognition to prevent significant morbidity and death. Treatment includes immediately stopping the offending agent and implementing supportive measures, as well as pharmacological interventions in more severe cases. Maintaining vigilant awareness of the clinical features of NMS to diagnose and treat the disorder early, however, remains the most important strategy by which physicians can keep mortality rates low and improve patient outcomes.

Neuroleptic malignant syndrome and closed head injury: A case report and review

Neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal neurological emergency. Fifty percent of traumatic brain injury (TBI) patients will have emotional disorders and post-traumatic agitations. Haloperidol is a neuroleptic antipsychotic medication commonly used in the traumatic brain injury patients due to its advantage of no effect on respiration and conscious level. But it is one of the common medications causing NMS. A 19-year-old male driver involved in the road traffic accident had an acute subdural hematoma, which was immediately evacuated. Postoperatively, he was awake. He was weaned from ventilator and extubated. He received 20 mg of intravenous haloperidol in divided doses with in 24 hours to control his agitation. Next day, he became drowsy, spastic, febrile, and tachycardic with labile blood pressure. He was diagnosed to have NMS, needed intubation, aggressive hydration and pharmacological treatment with dentrolene sodium and bromocriptin. He was weaned from ventilator and extubated on day 17. He was transferred to the ward and then discharged to be followed in out-patient clinic. NMS in head injury patient is rare and difficult to diagnose. Diagnosis of NMS should be suspected if two of the four cardinal signs and symptoms are developed following the use of neuroleptic or dopamine agonist medication withdrawal.

Síndrome neuroléptico maligno

El síndrome neuroléptico maligno es una emergencia médica rara, grave y potencialmente fatal, que se asocia al uso de medicamentos neurolépticos, cuya prevalencia es de aproximadamente 0,02% a 3% de los pacientes tratados, y se caracteriza por presentar hipertermia, rigidez muscular, alteración de la conciencia y disautonomía, además de la elevación de la creatinkinasa (CK), aunque muchas veces no es fácil reconocerlo debido a la variedad de diagnósticos diferenciales. La teoría más aceptada es la relacionada con la actividad dopaminérgica en el Sistema Nervioso Central afectando los núcleos de la base y al hipotálamo, por lo que dentro de su tratamiento se encuentra el uso de agonistas dopaminérgicos tales como la bromocriptina, además del resto de medidas generales. La mortalidad resulta directamente de las manifestaciones disautonómicas de la enfermedad y de las complicaciones sistémicas tales como cardiopatías y falla renal aguda secundaria a rabdomiolisis, si no se trata de manera precoz.

Neuroleptic malignant syndrome and serotonin syndrome

This chapter is focused on drug-induced hyperthermia with special regard to use of antipsychotics and antidepressants for the treatment of schizophrenia and major depression, respectively. Neuroleptic malignant syndrome (NMS) develops during the use of neuroleptics, whereas serotonin syndrome is caused mainly by serotoninergic antidepressants. Although both syndromes show various symptoms, hyperthermia is the main clinical manifestation. In this review we describe the historical background, clinical manifestations, diagnosis, and differential diagnosis of these two syndromes based on our observations on the experimental and clinical data.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: long-term treatment of schizophrenia

These guidelines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This second part of the guidelines covers the long-term treatment as well as the management of relevant side effects. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Syndrome catatonique et syndrome malin des neuroleptiques (à propos d’un cas)

We report the case of a young woman who deve-loped catatonic syndrome a few days after neuroleptic mali-gnant syndrome (NMS), arising the problem of the chronology of both affections. A 20-year old woman with an history of bipolar disorder, experienced an acute manic syndrome that made hospitalization necessary. Fourteen days after loxa-pine prescription, the patient developed a NMS (DSM IV criteria) dyskinesia, dysphagia, fever and alteration of cons-ciousness. Hepatic transaminases and muscular enzymes increased. Neuroleptic was immediately interrupted and benzodiazepines (Lorazepam) was started. Biological parameters were normalized after 7 days, hyperpyrexia decreased and extrapyramidal symptoms disappeared but manic symptoms persisted. Two weeks later, the patient presented nega-tivism, rigidity of the four limb, catalepsia and hyperpyrexia. She also had been anxious for death and presented auditory hallucinations. Bacteriological samples and computed tomography were normal. This catatonic symptoms did not decreased and electroconvulsive therapy (ECT) was necessary. After six ECT, she started standing up, walking, taking food and speaking. After 12 ECT, the clinical state was the same as it was before the acute episod. The patient was then treated with valproate and lorazepam for anxiety symptoms. Acute catatonie, a rare and life-threatening acute syndrome was described in psychosis before the advent of neuroleptic drugs. It's characterized by hyperexia, stupor alternated with exctement, rigidity. Many etiolologic factors have been reported for this affection: psychogenic, organic or toxic. Neuroletic malignant syndrome is a potentially fatal complication of neuroleptic treatment occuring in about 1% of patients treated with neuroleptic. This syndrome is characterised by consciousness alteration, extrapyramidal symptoms, autonomic and thermic disorders. Similar clinical and biological features in catatonia and neuroleptic malignant syndrome (NMS) suggest a relationship between both affections and common physiopathological mechanisms and neurochemical basis: a central dopamine deficiency. We believe like many authors that catatonia and NMS are two aspects of a same disease, arising the question of chronology of both affections: NMS precipitates catatonia evolution. In the same way, Revuelta reported a case of patient who presented a lethal catatonia worsened by neuroleptic malignant syndrome. Neuroleptic malignant syndrome may be related to a dopamine deficiency, predominantly in the basal ganglia and antérior hypothalamus. Dopaminergic impairment has also been postulated to explain hyperthermia and catatonic signs in acute catatonie. ECT increases cerebral concentrations of dopamine, GABA and noradrelanine. The efficacy of ECT also argues for the dopaminergic hypothesis. A relation between those syndromes are complexes. A catatonic syndrome is regard as an acute form of malignant syndrome. In the other way, a severity scores of malignant syndrome are correlated among catatonic signs. In this case report, we suggest that the neuroleptic malignant syndrome accelerate the evolution to catatonic syndrome.

The evaluation and management of patients with neuroleptic malignant syndrome

NMS is a rare but fatal syndrome that needs to be considered in the perioperative period. Although many aspects remain unexplored and controversial, with greater awareness of the condition, new concepts are coming into light. Definitive treatment guidelines remain an important issue to be addressed. Efforts have been initiated in that direction and all cases can be reported on a toll-free hotline ( 1-888-667-8367) or online (www.nmsis.org).

Autonomic dysfunction in the ICU patient

The sympathetic-parasympathetic balance may be altered in critically ill patients. Assessment of autonomic function provides information concerning prognosis, pathogenesis, and treatment strategies in ICU-relevant disorders. Proven tools are heart rate variability, baroreflex sensitivity, and, with limitations, cardiac chemoreflex sensitivity. New nonlinear methods are being evaluated that may predict risk more precisely in critically ill patients. This article summarizes application of these tools in the ICU. In addition, a model is introduced for investigating the impaired autonomic function in multiple organ dysfunction syndrome and sepsis, integrating extrinsic mechanisms and factors that are intrinsic to the cardiac tissue. By this combined approach, the authors hope to gain insight into the pathogenesis of multiple organ dysfunction syndrome. New pathophysiologic concepts are needed for the development of treatment strategies for this life-threatening disease.