Malignant neuroleptic syndrome

Malignant neuroleptic syndrome (CNS) is one of the most dangerous complications of neuroleptic therapy, often leading to the death of patients with schizophrenia.

[1],

Causes of the malignant neuroleptic syndrome

ZNS usually develops on the 2-3rd week of the onset of neuroleptic therapy and most often when powerful neuroleptics are used with a pronounced general and selective antipsychotic effect and high extrapyramidal activity such as thioprolazine (mazheptyl), haloperidol, trifluoperazine (tryptazine), and others.

[2], [3], [4], [5], [6]

Symptoms of the malignant neuroleptic syndrome

The first symptoms of malignant neuroleptic syndrome are characterized by the appearance of extrapyramidal symptoms in the form of akineto-rigid or hyperkinetic-rigid syndromes with simultaneous exacerbation of psychosis by extrapyramidal-psychotic type with predominance of catatonic disorders (stupor with catalepsy or negativism phenomena). With the weighting of the condition, the growth of somatovegetative disorders, the intensification of hyperthermia, there is a change in endogenous - onyroid-catatonic disorders - exogenous - amenitive and co-comedo-comatose.

Somatic disorders in malignant neuroleptic syndrome are characterized by hyperthermia of the central genesis in the range 37.5-40 ° C with an irregular character of the temperature curve during the day. The increase in body temperature is accompanied by a pronounced tachycardia (from 90 to 180 beats / min) with a characteristic pulse-temperature dissociation, increased respiration to 25-40 per minute, a violation of microcirculation with pallor and sweating of the skin, a fluctuation in blood pressure. In the development of malignant neuroleptic syndrome, somatovegetative disorders become heavier, hemodynamic changes (hypovolemia), violations of the basic parameters of homeostasis and, first of all, water and electrolyte balance. Clinically, signs of dehydration are manifested by dryness of the tongue, mucous membranes, a decrease in the skin turgor, sharpening of the facial features, which acquires a characteristic for toxicosis form. Electrolyte disturbances are characterized by a decrease in the concentration of potassium ions at normal or slightly lower concentrations of sodium ions.

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

Diagnostics of the malignant neuroleptic syndrome

In a general blood test, there are characteristic changes that 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 a slight leukocytosis, a decrease in 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.

[7], [8], [9], [10], [11]

Treatment of the malignant neuroleptic syndrome

Immediately cancel neuroleptics and prescribe intensive infusion-transfusion therapy aimed at correction of homeostasis. Treatment for malignant neuroleptic syndrome is performed according to the principles of intensive therapy with 24-hour drop infusions into the central or peripheral vein. Infusion therapy begins with replenishment of the volume of circulating blood and improvement of its rheological properties with the help of protein and plasma-substituting solutions - dry and native plasma, albumin, and also solutions of polyglucin and reopolyglucin. In addition to these drugs, haemodesis is administered. Further correction of the water-salt balance is performed by infusion of physiological solution, Ringer's solution and glucose solutions in various concentrations.

If the blood pressure falls, in case of insufficient effect from the infusion therapy, it is possible to use sympathomimetics-dopamine (2-5 ml of a 4% solution intravenously) and other drugs, cardiac glycosides (strophanthin 0.25-0.5 ml 0.05% solution, korglikon 1-2 ml of 0,06% solution), glucocorticoid hormones (prednisolone to 60-90 mg per day). Prednisolone is also used in severe hemorrhages, as it reduces the permeability of the vascular wall and has anti-shocks and antiallergic effects.

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

Essential in the system of intensive therapeutic measures is the fight against hyperpyrexia, against which rapid onset of threatening disturbances of homeostasis and cerebral edema. Parenteral administration of analgin has some antipyretic effect - body temperature decreases by 0.5-1.0 ° C, but does not completely normalize. Therefore, the introduction of drugs must be combined with physical methods of cooling - craniocerebral and general hypothermia, the imposition of ice packs on the area of large vessels, moist cold wraps, etc.

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

To combat psychomotor agitation, Seduxen (up to 60 mg / day), hexenal up to 1 g / day and sodium oxybutyrate (up to 10 g / day) injected intravenously into the drip and intramuscular are effective and at the same time safe preparations. Combined their application has a powerful sedative effect.

Intramuscular complex of intensive therapy of malignant neuroleptic syndrome also includes antihistamines dimedrol 1% - 2-5 ml / day, tavegil 1% - 2-5 ml / day.