Pediatric Neuroleptic Malignant Syndrome Treatment & Management

  • Author: Mary C Mancini, MD, PhD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Nov 21, 2011
 

Medical Care

Neuroleptic malignant syndrome (NMS) is a life-threatening medical emergency that requires monitoring and management in an ICU. Tailor intervention levels to the severity of illness.

  • Terminate the dopamine antagonist by withdrawing neuroleptic and neuroleptic malignant syndrome–potentiating drugs (eg, anticholinergics, lithium).
  • Supportive measures include the following:
    • Reduce body temperature using antipyretics, evaporative cooling, ice packs, and cooled intravenous (IV) fluids.
    • Treat suspected or secondary infections with empiric antibiotics.
    • Consider prophylactic intubation for patients with excessive salivation, swallowing dysfunction, coma, hypoxemia, acidosis, and severe rigidity with hyperthermia.
    • Maintain pulmonary, cardiovascular, and renal functions by monitoring and managing such complications as respiratory failure, renal failure, disseminated intravascular coagulation (DIC), and arrhythmias.
    • Sedate the patient.
  • Specific measures include the following:
    • A goal is rapid peripheral muscle relaxation. Rapid control of rigidity averts hyperthermia, rhabdomyolysis, renal failure, pneumonia, respiratory failure, DIC, and cardiovascular collapse.
    • Considering all the disadvantages of dantrolene (vide infra), using nondepolarizing neuromuscular blocking agents (eg, pancuronium, other newer agents) is reasonable, along with such sedatives as benzodiazepines, to achieve rapid, predictable, and effective control of rigidity and hyperthermia.
    • Dantrolene sodium directly relaxes muscles by inhibiting calcium release from the sarcoplasmic reticulum. Its disadvantages include the following: the mean response time is 1.7 days; rigidity and temperature reduction takes longer, effects are erratic, and effects are often incomplete; and dantrolene is a potentially hepatotoxic agent. Because of rigidity relieving action, it may offer another therapeutic modality for treatment of neuroleptic malignant syndrome (NMS).
    • Bromocriptine is a dopamine agonist that overcomes neuroleptic-induced dopaminergic blockade. It has also been used in combination with dantrolene.
    • Other agents that have been tried include amantadine, which enhances presynaptic release of dopamine, and levodopa/carbidopa, which increase presynaptic dopamine stores.
    • Antimuscarinic agents are not recommended because they are not only ineffective but also may worsen hyperthermia.
  • Consider electroconvulsive therapy (ECT). In 1987, Addonizio and Susman recommended ECT for persistently psychotic and agitated patients in whom distinguishing between neuroleptic malignant syndrome and lethal catatonia is difficult and in patients who run the risk of neuroleptic malignant syndrome recurring when neuroleptics are restarted.[5, 6]
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Consultations

  • Consultation with a psychiatrist may be prudent as the patient is stabilized in the ICU and for further follow-up care after the patient is discharged from the ICU.
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Contributor Information and Disclosures
Author

Mary C Mancini, MD, PhD  Professor and Chief of Cardiothoracic Surgery, Department of Surgery, Louisiana State University School of Medicine in Shreveport

Mary C Mancini, MD, PhD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Surgeons, American Surgical Association, Phi Beta Kappa, Society of Thoracic Surgeons, and Southern Surgical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Girish G Deshpande, MD, MBBS, FAAP  Associate Professor of Pediatrics, Interim Director and Division Chief of Critical Care Medicine, Department of Pediatrics, University of Illinois College of Medicine at Peoria; Consulting Staff, Division of Critical Care Medicine, Children's Hospital of Illinois at OSF St Francis Medical Center

Girish G Deshpande, MD, MBBS, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

G Patricia Cantwell, MD  FCCM, Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD  Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

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