Electroconvulsive therapy can be effective in severe or treatment resistant neuroleptic malignant syndrome patients. Anesthesia and use of muscle relaxant agents for electroconvulsive therapy in such patients may encounter anesthesiologists with specific challenges. This case report describes successful management of anesthesia in 28-year-old male patient undergoing eight electroconvulsive therapy sessions for treatment of neuroleptic malignant syndrome

Arasteh, Modabber

Nasseri, Karim

Shami, Shoaleh

English

PubMed

Electroconvulsive therapy can be effective in severe or treatment resistant neuroleptic malignant syndrome patients. Anesthesia and use of muscle relaxant agents for electroconvulsive therapy in such patients may encounter anesthesiologists with specific challenges. This case report describes successful management of anesthesia in 28-year-old male patient undergoing eight electroconvulsive therapy sessions for treatment of neuroleptic malignant syndrome.</jats:p

Modabber Arasteh

Shoaleh Shami

Karim Nasseri

Crossref

Hindawi Publishing CorporationCase Reports in MedicineVolume 2012, Article ID 585713, 3 pagesdoi:10.1155/2012/585713Case ReportPropofol-Remifentanil Combination forManagement of Electroconvulsive Therapy in a Patient withNeuroleptic Malignant SyndromeModabber Arasteh,1 Shoaleh Shami,2 and Karim Nasseri31 Department of Psychiatry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran2 Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran3 Department of Anesthesia, Kurdistan University of Medical Sciences, Beasat Hospital, Sanandaj, IranCorrespondence should be addressed to Karim Nasseri, nasseri k@muk.ac.irReceived 17 November 2011; Accepted 22 January 2012Academic Editor: S. KennedyCopyright © 2012 Modabber Arasteh et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.Electroconvulsive therapy can be eﬀective in severe or treatment resistant neuroleptic malignant syndrome patients. Anesthesiaand use of muscle relaxant agents for electroconvulsive therapy in such patients may encounter anesthesiologists with specificchallenges. This case report describes successful management of anesthesia in 28-year-old male patient undergoing eightelectroconvulsive therapy sessions for treatment of neuroleptic malignant syndrome.1. IntroductionNeuroleptic malignant syndrome (NMS) is a rare, unpre-dictable, and potentially fatal complication of certain anti-psychotic medications. The incidence and mortality ratesof NMS are approximately 0.07% to 2.2%, and 15%–25%,respectively [1]. Typical characteristics consist of hyperther-mia, altered level of conscious, muscle rigidity, catatonia,autonomic dysfunction, and elevation of Creatine Kinase(CK) level. All the previous findings are not necessaryfor diagnosis [1]. Bromocriptine, dantrolene, and benzodi-azepines are eﬀective in the treatment of NMS [2, 3]. Someauthors recommend that electroconvulsive therapy (ECT)may be eﬀective if signs and symptoms are resistant tosupportive care and pharmacotherapy [4, 5].There are a known sameness between the clinical symp-toms of NMS and malignant hyperthermia (MH) [6]; there-fore several reports have incited some controversy regardingthe safety of the use of known triggering agents of MHsuch as succinylcholine in patients with a history of NMS[6–8]. Anesthesia and muscle relaxation for ECT in suchpatients poses specific challenges to anesthesiologists. Thiscase report describes successful use of propofol-remifentanilwithout muscle relaxant in a patient undergoing ECT for thetreatment of NMS.2. Case ReportA 28-year-old male with a history of bipolar mood disorderand moderate mental retardation was admitted to hos-pital with increasing body temperature, muscle rigidity,diaphoresis, cognitive impairment, and some degrees ofimpaired consciousness. He had been taking thioridazineand valproate for a period of 6 months prior to hospitaladmission. On examination the patient was mute andshowed unusual postures characteristic of catatonia. His vitalsigns were as follows: temperature (38.2◦C), blood pressure131/82mmHg, heart rate 114 beats/min, and respiratoryrate 18. The CK level was markedly elevated (1245U/L)other laboratory results, including electrolytes, were slightlyelevated. He had several psychiatric hospitalizations, duringthe last years prior to the present episode, and livedin a chronic mental disorder institute. In family historyhis monozygotic twin had died with NMS manifestationsabout one year ago. Antipsychotic drugs were stopped, anddiagnosis of NMS was made, because the patient met three2 Case Reports in Medicinemajor (rigidity, hyperthermia, rising of CK) and three minorcriteria (tachycardia, diaphoresis, cognitive impairment) ofNMS. After six days because of progressive catatonia andmuscular rigidity ECT under anesthesia was considered.After preoxygenation with 100% O2 via face mask,anesthesia was induced with remifentanil 1.5 µg/kg andpropofol 1.5mg/kg IV slowly. Then the ECT stimulus wasapplied, and it produced an ensuing seizure. Succinylcholineand any other muscle relaxants were avoided. The doses ofpropofol and remifentanil remained fixed in all eight sessionsof ECT and there was no need for adding other anestheticor analgesic drugs for inducing anesthesia. Bilateral ECTwas administered using an ECT stimulator (brief pulse rate,analog-output ECT: type RF class 1. ARA 121; ARA CoLtd., Tehran, Iran). The first selected stimulus intensity was20% that induced a 32-second relatively tense seizure. Thestimulus intensity titrated based on previous seizure lengthand reached 50% in the last session. The range of seizureduration was 24–37 second (mean 27 second). The meantime from inducing anesthesia to returning spontaneousventilation was 8 minutes [7–10], and patient opened hiseyes by commend after 9–14 minutes (mean 11 minutes).The body temperature was measured on several occasionsfollowing ECT, at intervals of 3-4 hour. We did not observeany changes in body temperature. After eight ECT sessionsthat was done three times a week, the psychotic symptomsimproved considerably, CK level turned back toward normalranges slightly, and the patient was discharged from hospitalwithout further complications.3. DiscussionAlthough NMS and MH result from diﬀerent pathophysio-logical mechanisms [1, 9], however, they have some commonclinical features. So patients susceptible to NMS may bevulnerable to developing MH. ECT has been used as a treat-ment for NMS, because it supposedly increases circulatingcatecholamines, including dopamine, in the central nervoussystem [2, 3].Succinylcholine remains the most commonly used mus-cle relaxant to decrease the strong muscle contractionsassociated with ECT-induced seizure activity [10]. However,the use of this rapid and short-acting drug can accompanywith side eﬀects in patients with history of susceptibilityto MH, NMS, and catatonic schizophrenia [11, 12]. And ithas been suggested that the use of succinylcholine should beavoided in patients with a history of these diseases [13].Although nondepolarizing agents has been used success-fully in the treatment of NMS, some authors suggest thatthese drugs are associated with increases in temperature,CK levels, and leukocytosis [14] too, so it may be advisableto avoid administering depolarizing and nondepolarizingmuscle relaxants to patients with NMS. Based on thisinformation, we decided to perform ECT using remifentanil-propofol without muscle relaxant in this case. In the solerelated case report that we find, Franks et al. [15] performedECT on an MH susceptible patient using thiamylal withoutanymuscle relaxant, but the patient required physical controlduring the seizure and experienced severe muscle pain afterthe procedure.Remifentanil is an ultra-short-acting opioid with a rapidonset and an ultrashort context sensitive half-time [16].Propofol has significant myorelaxant properties on pharyn-geal and laryngeal structures, so it is the agent of choicefor intubation without muscle relaxant [17]. On the otherhand, there are some reports that the infusion of propofoland remifentanil slightly decrease both the train-of fourratio in comparison with the preoperative value [18] andsuccinylcholine-induced fasciculation [19, 20]. Based on theresults reported herein, and the aforementioned pharmaco-logical properties, individuals with NMSmay be at providinggeneral anesthesia using remifentanil-propofol boluses with-out neuromuscular blocking agents and were able to com-plete sessions of ECT without any associated complications.4. ConclusionIt is likely that combination of remifentanil-propofol withoutmuscle relaxants for ECT in NMS patients is safe and eﬀec-tive.References[1] Y. Asakura, Y. Fujiwara, and T. Komatsu, “The WHO analgesicladder and neuroleptic malignant syndrome,” Acta Anaesthesi-ologica Scandinavica, vol. 50, no. 10, pp. 1311–1312, 2006.[2] S. N. Caroﬀ, “Neuroleptic malignant syndrome,” in Neurolep-tic Malignant Syndrome and Related Conditions, S. C. Mann,S. N. Caroﬀ, P. E. Keck Jr, and A. Lazarus, Eds., pp. 1–44,American Psychiatric Publishing, Washington, DC, USA, 2ndedition, 2003.[3] P. Sakkas, J. M. Davis, P. G. Janicak, and Z. Wang, “Drugtreatment of the neuroleptic malignant syndrome,” Psy-chopharmacology Bulletin, vol. 27, no. 3, pp. 381–384, 1991.[4] F. Ozer, H. Meral, B. Aydin, L. Hanoglu, T. Aydemir, and T.Oral, “Electroconvulsive therapy in drug-induced psychiatricstates and neuroleptic malignant syndrome,” Journal of ECT,vol. 21, no. 2, pp. 125–127, 2005.[5] J. R. Strawn, P. E. Keck, and S. N. Caroﬀ, “Neurolepticmalignant syndrome,” American Journal of Psychiatry, vol. 164,no. 6, pp. 870–876, 2007.[6] K. J. McAllen and D. R. Schwartz, “Adverse drug reactionsresulting in hyperthermia in the intensive care unit,” CriticalCare Medicine, vol. 38, no. 6, pp. S244–S252, 2010.[7] S. N. Caroﬀ, H. Rosenberg, J. E. Fletcher, T. D. Heiman-Patterson, and S. C.Mann, “Malignant hyperthermia suscepti-bility in neuroleptic malignant syndrome,” Anesthesiology, vol.67, no. 1, pp. 20–25, 1987.[8] H. C. A. Silva, V. S. Bahia, R. A. A. Oliveira, P. E. Marchiori,M. Scaﬀ, and A. M. C. Tsanaclis, “Malignant hyperthermiasusceptibility in three patients with malignant neurolepticsyndrome,” Arquivos de Neuro-Psiquiatria, vol. 58, no. 3, pp.713–719, 2000.[9] A. Lazarus and H. Rosenberg, “Malignant hyperthermiaduring ECT,” American Journal of Psychiatry, vol. 148, no. 4,pp. 541–542, 1991.[10] P. Adnet, P. Lestavel, and R. Krivosic-Horber, “Neurolepticmalignant syndrome,” British Journal of Anaesthesia, vol. 85,no. 1, pp. 129–135, 2000.Case Reports in Medicine 3[11] R. C. Cooper, P. L. Baumann, and W. M. McDonald,“An unexpected hyperkalemic response to succinylcholineduring electroconvulsive therapy for catatonic schizophrenia,”Anesthesiology, vol. 91, no. 2, pp. 574–575, 1999.[12] E. Kelly and S. J. Brull, “Neuroleptic malignant syndrome andmivacurium: a safe alternative to succinylcholine?” CanadianJournal of Anaesthesia, vol. 41, no. 9, pp. 845–849, 1994.[13] H. Hermesh, D. Aizenberg, M. Lapidot, and H. Munitz, “Therelationship betweenmalignant hyperthermia and neurolepticmalignant syndrome,” Anesthesiology, vol. 70, no. 1, pp. 171–173, 1989.[14] S. A. Vitkun, R. V. Boccio, and P. J. Poppers, “Anesthetic man-agement of a patient with neuroleptic malignant syndrome,”Journal of Clinical Anesthesia, vol. 2, no. 3, pp. 188–191, 1990.[15] R. D. Franks, B. Aoueille, M. C. Mahowald, and N. Masson,“ECT use for a patient with malignant hyperthermia,” Ameri-can Journal of Psychiatry, vol. 139, no. 8, pp. 1065–1066, 1982.[16] S. Grant, S. Noble, A. Woods, J. Murdoch, and A. Davidson,“Assessment of intubating conditions in adults after inductionwith propofol and varying doses of remifentanil,” BritishJournal of Anaesthesia, vol. 81, no. 4, pp. 540–543, 1998.[17] K. McKeating, I. M. Bali, and J. W. Dundee, “The eﬀectsof thiopentone and propofol on upper airway integrity,”Anaesthesia, vol. 43, no. 8, pp. 638–640, 1988.[18] D. Lee, K. C. Lee, J. Y. Kim, Y. S. Park, and Y. J. Chang, “Totalintravenous anesthesia without muscle relaxant in a patientwith amyotrophic lateral sclerosis,” Journal of Anesthesia, vol.22, no. 4, pp. 443–445, 2008.[19] K. Nasseri, M. T. Arastheh, and S. Shami, “Pretreatment withremifentanil is associated with less succinylcholine-inducedfasciculation,” Middle East Journal of Anesthesiology, vol. 20,no. 4, pp. 515–520, 2010.[20] M. J. Yun, Y. H. Kim, Y. K. Go et al., “Remifentanilattenuates muscle fasciculations by succinylcholine,” YonseiMedical Journal, vol. 51, no. 4, pp. 585–589, 2010.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Case Reports in Medicine

Propofol-Remifentanil Combination for Management of Electroconvulsive Therapy in a Patient with Neuroleptic Malignant Syndrome

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Adverse drug reactions resulting in hyperthermia in the intensive care unit,”

Anesthetic management of a patient with neuroleptic malignant syndrome,”

Assessment of intubating conditions in adults after induction with propofol and varying doses of remifentanil,”

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Drug treatment of the neuroleptic malignant syndrome,”

ECT use for a patient with malignant hyperthermia,”

Electroconvulsive therapy in drug-induced psychiatric states and neuroleptic malignant syndrome,”

Malignant hyperthermia during ECT,”

Neuroleptic malignant syndrome and mivacurium: a safe alternative to succinylcholine?”

Neuroleptic malignant syndrome,”

Remifentanil attenuates muscle fasciculations by succinylcholine,”

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The eﬀects of thiopentone and propofol on upper airway integrity,”

The relationshipbetweenmalignanthyperthermiaandneuroleptic malignant syndrome,”

The WHO analgesic ladder and neuroleptic malignant syndrome,”

Total intravenous anesthesia without muscle relaxant in a patient with amyotrophic lateral sclerosis,”

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Propofol-Remifentanil Combination for Management of Electroconvulsive Therapy in a Patient with Neuroleptic Malignant Syndrome

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