Neuroleptic malignant syndrome associated with haloperidol use in critical care setting: should haloperidol still be considered the drug of choice for the management of delirium in the critical care setting?

Dixit, Deepali; Shrestha, Pranabh; Adelman, Marc

doi:10.1136/bcr-2013-010133

Cited by 9 publications

(3 citation statements)

References 17 publications

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“…These acute conditions are routinely managed with antipsychotic drugs such as short-acting injections of haloperidol and olanzapine [28]. NMS following exposure to antipsychotics in emergency, critical care, and trauma care settings has been reported [29][30][31][32]. Consistently, the result of the univariate analysis in our study indicated that presentation with acute conditions was a possible risk factor for NMS.…”

Section: Risk Of Neuroleptic Malignant Syndromesupporting

confidence: 85%

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

et al. 2020

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Background: Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available.Objectives: To ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS.Methods: We did a population-based study using data from the Hong Kong Hospital Authority's Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91 to 120 days before the index date. To adjust for potential time-trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications, and acute medical conditions.Results: 297 647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time-trend, and case-crossover adjusted for time-trend and potential confounders analysis were 8.00 (95% confidence interval 3.

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Section: Risk Of Neuroleptic Malignant Syndromesupporting

confidence: 85%

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

et al. 2020

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“…Psychostimulant intoxication, neuroleptic malignant syndrome and serotonin syndrome were reported to be clinically overlapping (Demirkiran et al, 1996). Dantrolene has been used successfully in the treatment of both methamphetamine toxicity and neuroleptic malignant syndrome (Dixit et al, 2013). Indeed, we have seen a decrease in myoglobin levels shortly after administration of dantrolene.…”

Section: )mentioning

confidence: 77%

Pervitin Intoxication with Two-peak Massive Myoglobinemia, Acute Kidney Injury and Marked Procalcitonin Increase Not Associated with Sepsis

2022

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Patients intoxicated with methamphetamine-like substances may present with myoglobinuria but rarely require admission. An 18-year-old female was admitted due to intoxication with pervitin, a methamphetamine derivative. She presented with an altered mental status, fever, and increased heart and respiratory rates. Biomarkers showed leukocytosis and markedly increased procalcitonin levels, suggestive of sepsis. However, blood cultures and infectious disease workup were unrevealing. Clinical course was heralded by rhabdomyolysis and myoglobinuria resulting in multi-organ failure including respiratory failure necessitating mechanical ventilation, hemodynamic compromise with need for inotropic support, and an acute renal failure requiring renal replacement therapy. Surprisingly, after a transient improvement, an unexpected second peak of myoglobin was observed on hospital day 5, controlled by intensifying the elimination methods, and administration of dantrolene. Acute kidney injury resolved by hospital day 15, and the patient could be discharged on day 22. While most patients with intoxications are discharged within 24 hours from emergency departments without being admitted, our case report highlights that the organ injury may evolve beyond the usual observation period, traditional renal-replacement therapies may not be sufficient to mitigate myoglobinemia with resulting acute kidney injury, and that procalcitonin may not be a reliable biomarker of infection in the setting of drug-induced rhabdomyolysis.

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“…Initial symptoms in NMS are mental status changes, followed by muscular rigidity, fever, and finally dysautonomia in 70% of cases [ 3 ]. The onset of NMS symptoms from antipsychotic exposure is variable, with 16% of cases occurring within 24 hours, 66% of cases within seven days, and nearly all cases within 30 days [ 4 ]. Because several other syndromes can result in similar symptoms, brain imaging, lumbar puncture (LP), and electroencephalogram (EEG) should be obtained to exclude organic causes [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

Development of Atypical Neuroleptic Malignant Syndrome After Treatment of Cocaine Intoxication: A Case Report and Literature Review

Miller¹,

Zezetko²,

Satodiya³

2023

Cureus

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Neuroleptic malignant syndrome (NMS) is a life-threatening condition classically associated with the use of antipsychotic medications. NMS commonly presents with initial mental status changes, followed by muscle rigidity, fever, and eventual dysautonomia. Cocaine intoxication can present with symptoms that are very similar to those found in NMS, making differentiating the two disorders challenging. We present the case of a 28-year-old female with a history of cocaine use disorder who presented with acute cocaine intoxication. She had severe agitation associated with her intoxication, requiring the use of antipsychotic medications. Subsequently, she developed atypical NMS from abrupt dopamine withdrawal after receiving the antipsychotics. Although overlapping dopamine pathways between cocaine use and NMS could deter one from this practice and guidelines recommend against it, antipsychotics are routinely used in the emergency setting for cocaine-associated agitation. This case highlights the need for a more standardized treatment protocol, provides an explanation of why treating cocaine intoxication with antipsychotics is inappropriate, and suggests that chronic cocaine users may be more prone to NMS in this scenario. Furthermore, this is a unique case because it describes atypical NMS in the context of cocaine intoxication, chronic cocaine use, and administration of antipsychotics to an antipsychotic-naïve patient.

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Neuroleptic malignant syndrome associated with haloperidol use in critical care setting: should haloperidol still be considered the drug of choice for the management of delirium in the critical care setting?

Cited by 9 publications

References 17 publications

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

Pervitin Intoxication with Two-peak Massive Myoglobinemia, Acute Kidney Injury and Marked Procalcitonin Increase Not Associated with Sepsis

Development of Atypical Neuroleptic Malignant Syndrome After Treatment of Cocaine Intoxication: A Case Report and Literature Review

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