[Electroconvulsive Therapy (ECT) in Neuroleptic Malignant Syndrome (NMS) on an Intensive Care Unit (ICU)]. / Elektrokonvulsivtherapie (EKT) bei malignem neuroleptischen Syndrom (MNS) auf Intensivstation.

A 57-year-old female patient with unclear somnolence was admitted to an Intermediate Care Unit (IMC) by an emergency physician. Several psychotropic drugs were on the medication list (quetiapine 450 mg/d, paroxetine 40 mg/d and perphenazine 12 mg/d), due to depression with psychotic features. As the patient's state deteriorated on day 3, she was intubated and transferred to Intensive Care Unit (ICU), where a malignant hyperthermia (MH) was assumed. The ICU's call to the MH hotline did not give a hint to consider a neuroleptic malignant syndrome (NMS) neither to consider electroconvulsive therapy (ECT). It was not until day 9 that a psychiatric consultation was undertaken, under the suspected diagnosis of NMS. On the same day ECT was performed, followed by a rapid remission of all clinical features and laboratory findings. Early consideration and application of ECT treatment for NMS on an ICU is life-saving.

Pharmacist-Initiated Management of a Suspected Case of Risperidone-Induced Neuroleptic Malignant Syndrome in an Aged-Care Resident. The Role of Residential Medication Management Reviews in Medication Safety.

A 70-year-old female aged-care resident was referred by her general practitioner for a residential medication management review after nurses reported difficulties with swallowing, episodes of hyperthermia, elevated blood pressure, and tachycardia. These symptoms were accompanied by increasing confusion and drowsiness. Risperidone had recently been prescribed to treat behavioral and psychological symptoms of dementia. This case study describes the pharmacist-initiated management of the symptoms through a national medication review program. It demonstrates the valuable role collaborative medication reviews play in managing adverse drug reactions in aged-care.

Risk of neuroleptic malignant syndrome in patients with bipolar disorder: a retrospective, population-based case-control study.

INTRODUCTION: Current data regarding risk factors of neuroleptic malignant syndrome (NMS) are limited. This study aims to examine factors associated with increased risk of NMS in patients with bipolar disorder. METHODS: A retrospective, population-based, case-control study was performed using a medical claims database covering January 1998 to December 2002. Fifty cases with a diagnosis of NMS were identified and matched with 800 controls. Conditional logistic regression analysis was used to estimate crude and adjusted odds ratios (ORs) of risk of NMS. RESULTS: Antipsychotic use was associated with an increased risk of NMS after controlling for other pharmacologic and clinical factors (OR = 2.36, 95% CI = 1.08-5.19). Other factors associated with an increased risk of NMS included being male (OR = 2.07, 95% CI = 1.07-4.02), confusion (OR = 2.91, 95% CI = 1.17-7.28), dehydration (OR = 3.99, 95% CI = 1.50-10.57), delirium (OR = 4.93, 95% CI = 2.07-11.72), and extrapyramidal symptoms (OR = 3.50, 95% CI = 1.10-11.09). CONCLUSIONS: Given the widespread use of antipsychotics for the treatment of bipolar disorder, clinicians should be vigilant of the potential pharmacologic and clinical factors associated with increased risk of NMS in patients with bipolar disorder.

Relating with professionals.

This paper addresses my difficulties as a carer in engaging with many professionals in mental health, both locally associated with my son's acute inpatient care, and nationally where policies are being developed and their implementation is pursued. All of us are affected by The Department of Health (DoH) Mental Health policies and their implementation by professionals has formed the way in which professionals relate with my son and myself. The way in which my son is impacted inextricably affects the way I relate to professionals. I think my difficulty in engaging lies in the relationships we all have with each another. In focusing on the process within our relationships, I attempt to raise professionals' awareness of what constitutes a relationship when we dialogue. As it takes two to engage in a dialogue, I perceive my difficulty is also the difficulty of the professionals. Carers are becoming increasingly involved in the training of mental health professionals and our combined difficulty needs to be resolved, so that we all benefit. In order to achieve positive progression, there needs to be a radical change within our relationship to provide ease of engagement from all parties. In this paper I tentatively suggest how this process can be achieved.

Toxin-induced hyperthermic syndromes.

Toxin-induced hyperthermic syndromes are important to consider in the differential diagnosis of patients presenting with fever and muscle rigidity. If untreated, toxin-induced hyperthermia may result in fatal hyperthermia with multisystem organ failure. All of these syndromes have at their center the disruption of normal thermogenic mechanisms, resulting in the activation of the hypothalamus and sympathetic nervous systems.The result of this thermogenic dysregulation is excess heat generation combined with impaired heat dissipation. Although many similarities exist among the clinical presentations and pathophysiologies of toxin-induced hyperthermic syndromes, important differences exist among their triggers and treatments. Serotonin syndrome typically occurs within hours of the addition ofa new serotonergic agent or the abuse of stimulants such as MDMA or methamphetamine. Treatment involves discontinuing the offending agent and administering either a central serotonergic antagonist, such as cyproheptadine or chlorpromazine, a benzodiazepine, or a combination of the two. NMS typically occurs over hours to days in a patient taking a neuroleptic agent; its recommended treatment is generally the combination of a central dopamine agonist, bromocriptine or L-dopa, and dantrolene. In those patients in whom it is difficult to differentiate between serotonin and neuroleptic malignant syndromes, the physical examination may be helpful:clonus and hyperreflexia are more suggestive of serotonin syndrome,whereas lead-pipe rigidity is suggestive of NMS. In patients in whom serotonin syndrome and NMS cannot be differentiated, benzodiazepines represent the safest therapeutic option. MH presents rapidly with jaw rigidity, hyperthermia, and hypercarbia. Although it almost always occurs in the setting of surgical anesthesia, cases have occurred in susceptible individuals during exertion. The treatment of MH involves the use of dantrolene. Future improvements in understanding the pathophysiology and clinical presentations of these syndromes will undoubtedly result in earlier recognition and better treatment strategies.

Recognition, assessment and management of neuroleptic malignant syndrome.

Neuroleptic malignant syndrome (NMS) is a potentially fatal idiosyncratic complication of neuroleptic treatment. It was first described in 1968 by Delay and Deniker, and is characterized by hyperthermia, extrapyramidal signs, autonomic dysfunction and altered mentation. They reported that 0.5% to 1.0% of the patients on neuroleptic therapy developed NMS. Several retrospective studies have reported the frequency of NMS between 0.02% to 2.44%. These variations in the incidence of NMS may be due to difference in patient population, awareness and experience of clinicians, prescribing habits, different diagnostic criteria, or methodological differences in survey methods.

Use of psychotropic medication in people with a learning disability.

The use of psychotropic medication for people with a learning disability is a controversial issue that has received much attention. This article explores some of the issues for learning disability nurses surrounding the use of psychotropic medication. There are concerns regarding the side-effects that antipsychotic medication can produce. Evidence suggests that some healthcare professionals, including learning disability nurses, need to keep themselves regularly updated on issues surrounding the use of these drugs such as efficacy, side-effects and interactions. Learning disability nurses need a clear understanding of the reasons behind the prescription of such powerful medication especially when it is used in the management of challenging behaviour. There are indications that learning disability nurses would support alternative approaches to medication such as the use of behavioural interventions. More healthcare professionals, direct carers and clients should be encouraged to become part of the multidisciplinary drug-review process.

Neuroleptic malignant syndrome: an assessment of registered psychiatric nurses' knowledge.

Neuroleptic Malignant Syndrome (NMS) is a potentially fatal complication of neuroleptic use and is frequently underdiagnosed by medical and nursing staff. The current project was undertaken to assess the knowledge registered psychiatric nurses (RPN) have of the signs, symptoms and interventions to be initiated in cases of NMS. A total of 126 RPN employed in a large tertiary inpatient facility and community mental health centre responded to a self-completed questionnaire. The results indicate that while the RPN in the study's sample demonstrated adequate knowledge of NMS, there was evidence to suggest that these RPN may actually lack confidence in their ability to identify and initiate appropriate interventions in suspected cases of NMS. Although RPN employed in the rehabilitation and psychogeriatric areas of the hospital had more years of experience in the mental health field, their overall knowledge of NMS was significantly lower than that of RPN employed in other clinical settings (F = 3.35; d.f. = 5119; P = 0.007). The findings underscore the importance of ongoing education for RPN employed within clinical mental health settings.

Anesthetic management of a patient with neuroleptic malignant syndrome.

Neuroleptic malignant syndrome is an uncommon, idiosyncratic, and sometimes life-threatening disorder associated with the use of neuroleptic drugs. The pathogenesis of neuroleptic malignant syndrome is uncertain, but it may be similar to that of malignant hyperthermia (MH). Some of the symptoms of neuroleptic malignant syndrome are similar to those of MH. We anesthetized a 17-year-old man with this syndrome multiple times for electroconvulsive therapy (ECT) using a variety of anesthetic techniques. In this patient, dantrolene pretreatment and the use of nondepolarizing muscle relaxants did not relieve symptoms of the syndrome, including fever and creatine phosphokinase (CPK) increases.

ECT as a treatment alternative for patients with symptoms of neuroleptic malignant syndrome.

The use of ECT as a treatment alternative in a clinical situation in which it is difficult to determine whether the patient is suffering from neuroleptic malignant syndrome (NMS) or an evolving catatonic state is investigated. Fourteen cases from the literature are reviewed and 3 new cases are presented. In 6 cases, ECT was rapidly effective in treating symptoms of NMS, but cardiac arrhythmias were reported in 4 cases. There was no evidence of malignant hyperthermia (MH) in patients receiving succinylcholine, suggesting that an association between NMS and MH may not be clinically relevant in patients being treated with ECT.