Rocuronium and sugammadex: An alternative to succinylcholine for electro convulsive therapy in patients with suspected neuroleptic malignant syndrome
Identifieur interne : 001D54 ( Pmc/Corpus ); précédent : 001D53; suivant : 001D55Rocuronium and sugammadex: An alternative to succinylcholine for electro convulsive therapy in patients with suspected neuroleptic malignant syndrome
Auteurs : Karthik G. Ramamoorthy ; H. Downey ; P. HawthorneSource :
- Journal of Anaesthesiology, Clinical Pharmacology [ 0970-9185 ] ; 2011.
Abstract
We report a case of presumptive neuroleptic malignant syndrome requiring muscle relaxation for electro-convulsive therapy. short acting muscle relaxation without the use of succinylcholine was achieved using rocvronivm reversed with the novel reversal agent sugammadex. We suggest that this combination is a safe and effective alternative to succinylcholine in such cases.
Url:
DOI: 10.4103/0970-9185.83687
PubMed: 21897513
PubMed Central: 3161467
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Rocuronium and sugammadex: An alternative to succinylcholine for electro convulsive therapy in patients with suspected neuroleptic malignant syndrome</title><author><name sortKey="Ramamoorthy, Karthik G" sort="Ramamoorthy, Karthik G" uniqKey="Ramamoorthy K" first="Karthik G." last="Ramamoorthy">Karthik G. Ramamoorthy</name><affiliation><nlm:aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</nlm:aff></affiliation></author><author><name sortKey="Downey, H" sort="Downey, H" uniqKey="Downey H" first="H" last="Downey">H. Downey</name><affiliation><nlm:aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</nlm:aff></affiliation></author><author><name sortKey="Hawthorne, P" sort="Hawthorne, P" uniqKey="Hawthorne P" first="P" last="Hawthorne">P. Hawthorne</name><affiliation><nlm:aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">21897513</idno><idno type="pmc">3161467</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3161467</idno><idno type="RBID">PMC:3161467</idno><idno type="doi">10.4103/0970-9185.83687</idno><date when="2011">2011</date><idno type="wicri:Area/Pmc/Corpus">001D54</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001D54</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Rocuronium and sugammadex: An alternative to succinylcholine for electro convulsive therapy in patients with suspected neuroleptic malignant syndrome</title><author><name sortKey="Ramamoorthy, Karthik G" sort="Ramamoorthy, Karthik G" uniqKey="Ramamoorthy K" first="Karthik G." last="Ramamoorthy">Karthik G. Ramamoorthy</name><affiliation><nlm:aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</nlm:aff></affiliation></author><author><name sortKey="Downey, H" sort="Downey, H" uniqKey="Downey H" first="H" last="Downey">H. Downey</name><affiliation><nlm:aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</nlm:aff></affiliation></author><author><name sortKey="Hawthorne, P" sort="Hawthorne, P" uniqKey="Hawthorne P" first="P" last="Hawthorne">P. Hawthorne</name><affiliation><nlm:aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Anaesthesiology, Clinical Pharmacology</title><idno type="ISSN">0970-9185</idno><idno type="eISSN">2231-2730</idno><imprint><date when="2011">2011</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>We report a case of presumptive neuroleptic malignant syndrome requiring muscle relaxation for electro-convulsive therapy. short acting muscle relaxation without the use of succinylcholine was achieved using rocvronivm reversed with the novel reversal agent sugammadex. We suggest that this combination is a safe and effective alternative to succinylcholine in such cases.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Khan, A" uniqKey="Khan A">A Khan</name></author><author><name sortKey="Mirolo, Mh" uniqKey="Mirolo M">MH Mirolo</name></author><author><name sortKey="Hughes, D" uniqKey="Hughes D">D Hughes</name></author><author><name sortKey="Bierut, L" uniqKey="Bierut L">L Bierut</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Devanand, Dp" uniqKey="Devanand D">DP Devanand</name></author><author><name sortKey="Sackeim, Ha" uniqKey="Sackeim H">HA Sackeim</name></author><author><name sortKey="Finck, Ad" uniqKey="Finck A">AD Finck</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kelly, D" uniqKey="Kelly D">D Kelly</name></author><author><name sortKey="Bruell, Sj" uniqKey="Bruell S">SJ 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Ag" uniqKey="Kadar A">AG Kadar</name></author><author><name sortKey="Kramer, Ba" uniqKey="Kramer B">BA Kramer</name></author><author><name sortKey="Barth, Mc" uniqKey="Barth M">MC Barth</name></author><author><name sortKey="White, Pf" uniqKey="White P">PF White</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="White, Pf" uniqKey="White P">PF White</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Anaesthesiol Clin Pharmacol</journal-id><journal-id journal-id-type="publisher-id">JOACP</journal-id><journal-title-group><journal-title>Journal of Anaesthesiology, Clinical Pharmacology</journal-title></journal-title-group><issn pub-type="ppub">0970-9185</issn><issn pub-type="epub">2231-2730</issn><publisher><publisher-name>Medknow Publications Pvt Ltd</publisher-name><publisher-loc>India</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">21897513</article-id><article-id pub-id-type="pmc">3161467</article-id><article-id pub-id-type="publisher-id">JOACP-27-380</article-id><article-id pub-id-type="doi">10.4103/0970-9185.83687</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Rocuronium and sugammadex: An alternative to succinylcholine for electro convulsive therapy in patients with suspected neuroleptic malignant syndrome</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Ramamoorthy</surname><given-names>Karthik G.</given-names></name><xref ref-type="aff" rid="aff1"></xref><xref ref-type="corresp" rid="cor1"></xref></contrib><contrib contrib-type="author"><name><surname>Downey</surname><given-names>H</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Hawthorne</surname><given-names>P</given-names></name><xref ref-type="aff" rid="aff1"></xref></contrib></contrib-group><aff id="aff1">Department of Anaesthesia, Consultant, Letterkenny General Hospital, Letterkenny, Ireland</aff><author-notes><corresp id="cor1"><bold>Address for correspondence:</bold> Dr. Karthik G. Ramamoorthy, 23, Fox Hills, Letterkenny Ireland, Letterkenny, Ireland E-mail: <email xlink:href="rkganeshdr@gmail.com">rkganeshdr@gmail.com</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jul-Sep</season><year>2011</year></pub-date><volume>27</volume><issue>3</issue><fpage>380</fpage><lpage>382</lpage><permissions><copyright-statement>© Journal of Anaesthesiology Clinical Pharmacology</copyright-statement><copyright-year>2011</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-sa/3.0"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><abstract><p>We report a case of presumptive neuroleptic malignant syndrome requiring muscle relaxation for electro-convulsive therapy. short acting muscle relaxation without the use of succinylcholine was achieved using rocvronivm reversed with the novel reversal agent sugammadex. We suggest that this combination is a safe and effective alternative to succinylcholine in such cases.</p></abstract><kwd-group><kwd>Neuroleptic malignant syndrome</kwd><kwd>electro convulsive therapy</kwd><kwd>succinyl choline</kwd><kwd>rocuronium</kwd><kwd>sugammadex</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="sec1-1"><title>Introduction</title><p>Since 1938, when the use of electro convulsive therapy (ECT) was first described in the literature, it has played a major role in psychiatric medicine.[<xref ref-type="bibr" rid="ref1">1</xref>] Also, since its introduction in the 1950's, succinylcholine has remained the most common muscle relaxant used to modify the motor effects of ECT. A coincidental association between neuroleptic malignant syndrome (NMS) and malignant hyperthermia (MH) may render succinylcholine unsafe in some patients undergoing ECT. There is conflicting evidence for this in the literature.[<xref ref-type="bibr" rid="ref2">2</xref><xref ref-type="bibr" rid="ref3">3</xref>]</p></sec><sec sec-type="cases" id="sec1-2"><title>Case Report</title><p>A 69-year-old woman, of weight 50 kg, was admitted to the psychiatric service requiring anesthesia for ECT to treat severe depression. She presented with a presumptive diagnosis of NMS, Parkinson's disease, rheumatoid arthritis, celiac disease, and hypertension. Current medications included dantrolene, bromocriptine, amlodipine, thiamine, and calcium. She was found to be non-verbal, rigid, and posturing. She had an edentulous airway, with Mallampatti score of II, and had limited neck movement. Magnetic resonance imaging (MRI) showed moderate degenerative changes at C3/4 vertebrae and a normal odontoid peg. A review of other systems was unremarkable. Her heart rate was 80/min, blood pressure was 130/86 mm Hg, and temperature was 36.5°C.</p><p>All ECT procedures were performed in the operating theatre with standard monitoring. ECT was administered using Thymatron System IV (SOMATICS Lake Bluff, IL, USA), with bitemporal electrode placement. Induction of anesthesia was accomplished with propofol 80 mg and rocuronium 50 mg (1 mg/kg).The patient was hyperventilated by face mask with 100% O<sub>2</sub> through a vapor-free Datex-Ohmeda anesthesia machine. Three minutes after the administration of rocuronium and deep blockade confirmed with a neuromuscular monitor (Life -Tech model ms IV; Mini Stim), ECT was performed. The treatment produced a satisfactory motor and electroencephalogram (EEG) seizure. The mean EEG endpoint of seizure was 26.5 sec. Muscle relaxation with rocuronium was satisfactory in preventing violent muscle contraction. Sugammadex 800 mg (16 mg/ kg) was administered after ECT approximately 5 min after the administration of rocuronium. Recovery of train of four (TOF) ratio to 0.9 was within 2 min and the time to first spontaneous breath was within 3 min from the administration of sugammadex. HR, BP, and temperature were measured before anesthesia induction, pre-seizure, post-seizure, and every minute for 10 min thereafter, and remained stable throughout the procedure. Rocuronium and sugammadex were employed in all subsequent ECTs and found to be an excellent and safe alternative to succinylcholine in this patient.</p></sec><sec sec-type="discussion" id="sec1-3"><title>Discussion</title><p>Neuroleptic malignant syndrome is a relatively rare but potentially fatal complication of the use of neuroleptic drugs.[<xref ref-type="bibr" rid="ref4">4</xref>] NMS has been associated with all dopamine blocking drugs such as antipsychotics (phenothiazines, butyrophenones, thioxanthenes, benzamides, and recent drugs such as clozapine and risperidone)[<xref ref-type="bibr" rid="ref5">5</xref>] and antiemetics (metoclopramide, prochlorperazine, promethazine, and droperidol).[<xref ref-type="bibr" rid="ref5">5</xref>] Abrupt withdrawal of dopaminergic drugs may also produce an NMS-like condition.</p><p>NMS pathophysiology is complex and probably involves an interplay between multiple central and systemic pathways and neurotransmitters. Dopamine blockade in the hypothalamus is believed to contribute to thermoregulatory failure, and blockade in the nigrostriatal system may contribute to muscle rigidity and hypermetabolism. The loss of dopaminergic input to the anterior cingulate–medial orbitofrontal circuit and the lateral orbitofrontal circuit likely contributes to changes in the mental status and catatonic features seen in NMS.[<xref ref-type="bibr" rid="ref6">6</xref>] These medications in susceptible individuals block dopamine, thereby triggering NMS. NMS typically develops over a period of 24-78 hours following antipsychotic initiation, although the condition can occur at any time during treatment.</p><p>Diagnosis of NMS is based on clinical criteria. The presence of all three major or two major and four minor manifestations indicates a high probability of NMS.[<xref ref-type="bibr" rid="ref7">7</xref>] [<xref ref-type="table" rid="T1">Table 1</xref>]</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p>Clinical criteria for diagnosis of NMS[<xref ref-type="bibr" rid="ref7">7</xref>]</p></caption><graphic xlink:href="JOACP-27-380-g001"></graphic></table-wrap><p>NMS is a self-limiting condition once the offending agent has been discontinued. General symptomatic treatment such as hydration, nutrition, reduction of fever, and treatment of secondary complications (hypoxia, acidosis, renal failure) are essential.[<xref ref-type="bibr" rid="ref8">8</xref>] Specific treatments include lorazepam, dantrolene, bromocriptine, and amantadine.[<xref ref-type="bibr" rid="ref8">8</xref>] ECT itself also appears to be rapidly effective.[<xref ref-type="bibr" rid="ref9">9</xref>]</p><p>Muscle relaxants are often administered during ECT to prevent myalgia and more serious musculoskeletal complications.[<xref ref-type="bibr" rid="ref10">10</xref>] Succinylcholine remains the most commonly used muscle relaxant,[<xref ref-type="bibr" rid="ref11">11</xref>] but is not recommended in patients with a history of susceptibility to MH, NMS, catatonic schizophrenia or organophosphate poisoning.[<xref ref-type="bibr" rid="ref12">12</xref><xref ref-type="bibr" rid="ref13">13</xref>] There are clinical reports describing the use of other muscle relaxants in this high-risk group of patients.</p><p>Mivacurium is the drug most often administered as an alternative to succinylcholine during ECT.[<xref ref-type="bibr" rid="ref3">3</xref>] However, a dose-finding study reported that only a full intubating dose of mivacurium (0.2 mg/kg) was associated with effective muscle relaxation during ECT.[<xref ref-type="bibr" rid="ref14">14</xref>] At least two clinical studies have demonstrated that at higher doses, it causes clinically significant histamine release and hypotension.[<xref ref-type="bibr" rid="ref11">11</xref><xref ref-type="bibr" rid="ref15">15</xref>] Atracurium has been used as an alternative, but a dose of 0.5 mg/kg required more time to achieve a satisfactory TOF ratio and recovery.[<xref ref-type="bibr" rid="ref16">16</xref><xref ref-type="bibr" rid="ref17">17</xref>] Rapacuronium at doses of 0.6-0.8 mg/kg provided effective muscle relaxation for ECT and was readily reversible with edrophonium and atropine. 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