Malignant neuroleptic syndrome.

Neuroleptic malignant syndrome (NMS) is one of the most dangerous complications of neuroleptic therapy, often leading to death in patients with schizophrenia.

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Causes of malignant neuroleptic syndrome

NMS usually develops in the 2nd-3rd week of the start of neuroleptic therapy and most often with the use of powerful neuroleptics with pronounced general and selective antipsychotic action and high extrapyramidal activity, such as thioprolerazine (mazheptil), haloperidol, trifluoperazine (triftazin), etc.

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Symptoms of malignant neuroleptic syndrome

The first symptoms of malignant neuroleptic syndrome are characterized by the appearance of extrapyramidal symptoms in the form of akinetic-rigid or hyperkinetic-rigid syndromes with simultaneous exacerbation of psychosis of the extrapyramidal-psychotic type with a predominance of catatonic disorders (stupor with phenomena of catalepsy or negativism). With the aggravation of the condition, the increase of somatovegetative disorders, and the intensification of hyperthermia, there is a change from endogenous - oneiroid-catatonic disorders to exogenous - amentive and soporous-comatose ones.

Somatic disorders in malignant neuroleptic syndrome are characterized by hyperthermia of central genesis in the range of 37.5-40 °C with an irregular temperature curve during the day. An increase in body temperature is accompanied by pronounced tachycardia (from 90 to 180 beats per minute) with characteristic pulse-temperature dissociation, increased respiratory rate to 25-40 per minute, impaired microcirculation with pallor and sweating of the skin, and fluctuations in blood pressure. In the process of development of malignant neuroleptic syndrome, somatovegetative disorders worsen, hemodynamic shifts (hypovolemia) appear, as well as disturbances of the main parameters of homeostasis, primarily water and electrolyte balance. Clinically, signs of dehydration are manifested by dry tongue, mucous membranes, decreased skin turgor, and sharpening of facial features, which acquires a look characteristic of toxicosis. Electrolyte disturbances are characterized by a decrease in the concentration of potassium ions with a normal or slightly reduced concentration of sodium ions.

The increase in hemodynamic disorders and disturbances in water-electrolyte balance against the background of hyperthermia lead to the development of cerebral edema, a drop in cardiac activity and are the direct cause of death in malignant neuroleptic syndrome.

Diagnostics of malignant neuroleptic syndrome

In the general blood test, characteristic changes are noted, which, along with clinical symptoms, can be used for diagnosis. Characteristic is an increase in ESR to 15-70 mm/h, a decrease in the percentage of lymphocytes to 3-17 with minor leukocytosis, a decrease in the serum protein content to 45-65 g/l, an increase in urea levels to 5.8-12.3 mmol/l and creatinine to 0.15 mmol/l.

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Treatment of malignant neuroleptic syndrome

Neuroleptics are immediately discontinued and intensive infusion-transfusion therapy aimed at correcting homeostasis is prescribed. Treatment of malignant neuroleptic syndrome is carried out according to the principles of intensive therapy with round-the-clock drip infusions into the central or peripheral vein. Infusion therapy begins with replenishment of the circulating blood volume and improvement of its rheological properties using protein and plasma-substituting solutions - dry and native plasma, albumin, as well as polyglucin and rheopolyglucin solutions. Along with these drugs, hemodesis is administered. Further correction of the water-salt balance is carried out by infusions of physiological solution, Ringer's solution and glucose solutions in various concentrations.

In case of a drop in blood pressure, in case of insufficient effect from the infusion therapy, it is possible to use sympathomimetics - dopamine (2-5 ml of 4% solution intravenously by drip) and other drugs, cardiac glycosides (strophanthin 0.25-0.5 ml of 0.05% solution, corglycon 1-2 ml of 0.06% solution), glucocorticoid hormones (prednisolone up to 60-90 mg per day). Prednisolone is also used for severe hemorrhages, as it reduces the permeability of the vascular wall and also has an anti-shock and anti-allergic effect.

To prevent hypercoagulation phenomena, heparin is administered at a dose of 25,000-30,000 U under the control of blood clotting time.

Of significant importance in the system of intensive therapeutic measures is the fight against hyperpyrexia, against the background of which threatening disturbances of homeostasis and cerebral edema quickly occur. Parenteral administration of analgin has some antipyretic effect - body temperature decreases by 0.5-1.0 °C, but does not return to normal completely. Therefore, the administration of drugs should be combined with physical methods of cooling - craniocerebral and general hypothermia, application of ice packs to the area of large vessels, wet cold wraps, etc.

Frequent development of profound clouding of consciousness with the transition of oneiroid-catatonic status to amentia in patients with malignant neuroleptic syndrome, the appearance of signs of stunning and stupor necessitates the use of drugs with neurometabolic action (nootropics). The most effective of these drugs is piracetam (nootropil). It is administered intravenously by drip in a dose of 5-20 ml (25-100 mg of 20% solution).

To combat psychomotor agitation, effective and at the same time safe drugs are seduxen (at a dose of up to 60 mg/day), hexenal up to 1 g/day and sodium oxybutyrate (up to 10 g/day), administered intravenously by drip and intramuscularly. Their combined use has a powerful sedative effect.

The complex intensive therapy regimen for malignant neuroleptic syndrome also includes antihistamines: diphenhydramine 1% - 2-5 ml/day, tavegil 1% - 2-5 ml/day.