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Should neuroleptic malignant syndrome be treated in a private psychiatric hospital or a general hospital?
Commentary and Perspective From time to time, the Journal receives manuscripts that can be thought of as opinion pieces, essays, or editorial comment on matters of topical interest. Such submissions will be refereed in the usual fashion and if suitable, published in this section. The Editorial Board invites Letters to the Editor or rebutting commentary with the understanding that all submissions are subject to editing.
Should Neuroleptic Malignant Syndrome Be Treated in a Private Psvchiatric Hospital or a General Hospital? J Arthur Lazarus, M.D.
Abstract: Neuroleptic malignant syndrome (NMS) has come to be recognized as one of the most serious adverse reactions to neuroleptic therapy. Complications may include cardiopuimonary failure, rkabdomyolysis and renal failure, disseminated intravascular coagulation, infection, dehydration, and shock. This article points out the need for intensive medical management for patients with NMS and questions whether private psychiatric hospitals are adequate to the task.
The neuroleptic malignant syndrome (NMS) is one of the most severe adverse reactions known to neuroleptic medication. It is diagnosed clinically by the presence of hyperthermia, muscle rigidity, and at least three of the following: altered mental status, tachycardia, labile blood pressure, tachypnea or hypoxia, increased creatine phosphokinase (CPK) or myoglobinuria, leukocytosis, and metabolic acidosis [ 11. Medical morbidity is not only embodied in the diagnosis, but, more important, it underscores the seriousness of the disorder. Only about 60 cases of NMS were reported at the time of a comprehensive 1980 review [2]. The number of cases published since then has increased almost tenfold [3]. Although the exact incidence of NMS is still a matter of debate, an estimate of 1% is not unrealistic [l]. In our 147-bed psychiatric hosFrom Temple University School of Medicine and Diagnostic Evaluation Unit, Philadelphia Psychiatric Center, Philadelphia, Pennsylvania. Address reprint requests to: Arthur Lazarus, M.D., Philadelphia Psychiatric Center, Ford Road and Monument Avenue, Philadelphia, PA 19131.
General Hospital Psychiatry 12, 245-247, 1990 8 1990 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
pita1 in Philadelphia, we average 2150 admissions per year; approximately 70% of patients receive neuroleptics. Thus, if our experience is typical of others, we would expect about 15 cases of NMS yearly. In fact, this prediction appears to be consistent with the experience of other groups [4,5]. Although various agents (e.g., amantadine, bromocriptine, and dantrolene) have been used in the therapy of NMS, the cornerstone of treatment remains prompt discontinuation of neuroleptics and intensive medical and nursing care [6,7]. From this perspective, one may ask whether an acute episode of NMS can be adequately treated in a freestanding psychiatric hospital. Consider the odyssey of one patient with NMS who was not accurately diagnosed despite evaluation by many well-trained physicians in four different hospitals [B]. The authors of this report made a plea for maintaining general medical personnel in inpatient psychiatric settings. They commented, “Today, when many of our hospitals for the mentally ill, at least in the public sector, are witnessing a major loss of trained medical personnel, the risk of potentially lethal NMS grows greater” [8, pp. 45-461. More to the point, Janati and Webb [9] observed that “because of the lability of the patient’s status, admission to an intensive care unit is essential” (p. 1570). In a review of 55 cases of NMS, Lavie et al. [lo] found that more than one third of patients did, in fact, require admission to intensive care units. Close medical monitoring and supportive treatment beyond that which can reasonably be pro245
ISSN 0163-8343/90/$3.50
A. Lazarus
vided in a private psychiatric hospital may be necessary for patients with NMS for several reasons. Multidisciplinary treatment is often necessary in the acute phase of NMS, and such treatment is more readily available in a general medical setting. Not infrequently, consultation is required with an internist, a critical-care specialist, a neurologist, or an anesthesiologist (if use of dantrolene is contemplated). Later in the course of therapy, physiotherapy and consultation with a physiatrist may be needed. In the event of rapid medical deterioration or serious complications, admission to an intensive care unit doesbecome essential. Highly specialized treatment, such as cardiac monitoring, renal dialysis, and respiratory ventilation, may be necessary. From a nursing standpoint, patients with NMS are also probably better monitored in a medical hospital [11,12]. Skilled nursing care outside the scope of that normally provided by psychiatric nurses may include complicated intravenous therapy, nasogastric tube feedings and maintenance, and specialized nursing care involved in the treatment of immobile patients to prevent thromboembolism and decubitus ulcers: assistance with ambulation, skin care, and body positioning. Clearly, monitoring for weight loss, fever, tachycardia, diaphoresis, muscular rigidity, and fluid intake and urinary output is more easily accomplished in a medical intensive setting. In one case of NMS that was initially misdiagnosed as catatonic schizophrenia, the correct diagnosis was made only after astute intensive care nurses pointed out that the patient appeared physically rather than mentally ill [13, and oral communication 19851. The inadequacy of private hospitals for many other neuropsychiatic conditions could also be questioned-advanced anorexia nervosa, delirium tremens, acute catatonic excitement-not to mention the many threatening medical conditions in geriatric psychiatry. Regrettably, the severity of medical illness may not be a significant factor in determining the locus of care of psychiatric patients [14]. However, implying that patients with NMS cannot be treated adequately in a freestanding psychiatric facility could be unduly alarmist, if not insulting to the staff of those facilities that do have strong primary medical skills and collaborative consulting relationships. Furthermore, it is recognized that not all cases of NMS are severe enough to warrant a blanket recommendation for treatment in a medical hospital. Some cases may be mild in that they may not show severe rigidity and hy246
perthermia, and symptoms may abate in the face of ongoing neuroleptic treatment [4]. The decision to transfer a psychiatric patient to a general medical hospital or an intensive care unit is one that is not made easily. Although a few studies have examined the transfer of patients from medical-surgical inpatient settings to psychiatric inpatient units [14,15], no studies have investigated the process in reverse, certainly not with respect to patients with NMS. The decision to transfer a psychiatric patient to a more intense medical setting appears to be made empirically depending on the severity and duration of medical complications, previous response to treatment, and the availability of facilities and personnel that would ensure proper medical care. Transfer to a general hospital is recommended when patients with NMS develop renal failure, cardiopulmonary failure, disseminated intravascular coagulation, aspiration pneumonia, widespread infection, pulmonary embolism, prolonged seizure activity, profound dehydration, or shock. Knowledgeable staff must be able to differentiate acute from chronic illness and understand adverse drug reactions and possible drug interactions [16]. They should be able to demonstrate skills in physical and laboratory assessment as well as technical skills such as insertion of intravenous lines, arterial lines and feeding tubes, administration of intravenous and hyperalimentation solutions, and use of intravenous pumps. Both medical and nursing staff should be well versed in procedures used in cardiac and respiratory arrest, including airway management, oxygen supplementation, interpretation of EKG, and other basic life support measures. Any facility treating patients suspected of having NMS should be able simultaneously to investigate other conditions resembling NMS, especially infectious, neurologic, and toxic-metabolic conditions [17]. This would include having provisions for chest xray, EKG, EEG, and routine blood and urine tests. A prompt check for abnormalities associated with NMS, for example, leukocytosis, elevated CPK, and myoglobinuria should be possible. Perhaps it is not a coincidence that no deaths were reported in a series of 20 patients afflicted with 24 episodes of NMS when they were treated in a general hospital with vigorous supportive therapy [7]. Likewise, a recent study [18] of over 200 published reports of NMS indicated that although mortality from NMS has been steadily declining, a positive outcome is not necessarily related to therapy with dopaminergic agents and dantrolene.
Neuroleptic
These studies suggest there is increased medical morbidity when intensive supportive care is unavailable.
References 1. Lazarus
2. 3.
4.
5.
6.
7.
8.
A, Mann SC, Caroff SN: The Neuroleptic Malignant Syndrome and Related Conditions. Washington, DC, American Psychiatric Press, 1989 Caroff SN: The neuroleptic malignant syndrome. J Clin Psychiatry 41:79-83, 1980 Sakkas P, Davis JM, Jin H: Vulnerability and presentation of NMS. Presented at the 142nd annual meeting of the American Psychiatric Association, San Francisco, May 9, 1989 (new research abstract) Addonizio G, Susman VL, Roth SD: Symptoms of neuroleptic malignant syndrome in 82 consecutive inpatients. Am J Psychiatry 143:1587-1590, 1986 Keck PE Jr, Pope HG Jr, McElroy SL: Frequency and presentation of neuroleptic malignant syndrome: A prospective study. Am J Psychiatry 1441344-1346, 1987 Kaufmann CA, Wyatt RJ: Neuroleptic malignant syndrome. In Meltzer HY (ed), Psychopharmacology: The Third Generation of Progress. New York, Raven Press, 1987, pp. 1421-1430 Rosebush P, Stewart T: A prospective analysis of 24 episodes of neuroleptic malignant syndrome. Am J Psychiatry 146:717-725, 1989 Ingraham MR, Joo CJ, Tovin K: Neuroleptic malignant syndrome: A case report. Int J Psychiatry Med 12:43-47, 1982
Malignant
Syndrome
9. Janati A, Webb RT: Successful treatment of neuroleptic malignant syndrome with bromocriptine. South Med J 79:1567-1571, 1986 10. Lavie CJ, Olmstead TR, Ventura HO, Lepler BJ: Neuroleptic malignant syndrome: An underdiagnosed reaction to neuroleptic agents? Postgrad Med 80:171178, 1986 11. Cahill C, Arana GW: Navigating neuroleptic malignant syndrome. Am J Nurs 86:671-673, 1986 12. Keltner NL, McIntyre CW: Neuroleptic malignant syndrome. J Neurosurg Nurs 17:362-366, 1985 13. Weinberger DR, Kelly MJ: Catatonia and malignant syndrome: A possible complication of neuroleptic administration. J Nerv Ment Dis 165:263-268, 1977 14. Leibenluft E, Goldberg RL, Miller J, et al: Who gets treated where: A study of patients transferred and not transferred from a consultation-liaison service to a general hospital psychiatry unit. Gen Hosp Psychiatry 11:182-186, 1989 15. Weimer SR, Fenn HH: Patient transfers from medical and surgical settings to psychiatric inpatient wards. Gen Hosp Psychiatry 4:179-185, 1982 16. Cowart T, Stoudemire A: Nursing staff development and facility design for medical-psychiatry units. Gen Hosp Psychiatry 11:36-47, 1989 17. Vinogradov S, Brody S, Csernasky JG, et al: Consultation in clinical psychopharmacology: Neuroleptic malignant syndrome. Hosp Formul 23:646-653, 1988 18. Shalev A, Hermesh H, Munitz H: Mortality from neuroleptic malignant syndrome. J Clin Psychiatry 50:18-25, 1989
247
Should Neuroleptic Malignant Syndrome Be Treated in a Private Psvchiatric Hospital or a General Hospital? J Arthur Lazarus, M.D.
Abstract: Neuroleptic malignant syndrome (NMS) has come to be recognized as one of the most serious adverse reactions to neuroleptic therapy. Complications may include cardiopuimonary failure, rkabdomyolysis and renal failure, disseminated intravascular coagulation, infection, dehydration, and shock. This article points out the need for intensive medical management for patients with NMS and questions whether private psychiatric hospitals are adequate to the task.
The neuroleptic malignant syndrome (NMS) is one of the most severe adverse reactions known to neuroleptic medication. It is diagnosed clinically by the presence of hyperthermia, muscle rigidity, and at least three of the following: altered mental status, tachycardia, labile blood pressure, tachypnea or hypoxia, increased creatine phosphokinase (CPK) or myoglobinuria, leukocytosis, and metabolic acidosis [ 11. Medical morbidity is not only embodied in the diagnosis, but, more important, it underscores the seriousness of the disorder. Only about 60 cases of NMS were reported at the time of a comprehensive 1980 review [2]. The number of cases published since then has increased almost tenfold [3]. Although the exact incidence of NMS is still a matter of debate, an estimate of 1% is not unrealistic [l]. In our 147-bed psychiatric hosFrom Temple University School of Medicine and Diagnostic Evaluation Unit, Philadelphia Psychiatric Center, Philadelphia, Pennsylvania. Address reprint requests to: Arthur Lazarus, M.D., Philadelphia Psychiatric Center, Ford Road and Monument Avenue, Philadelphia, PA 19131.
General Hospital Psychiatry 12, 245-247, 1990 8 1990 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
pita1 in Philadelphia, we average 2150 admissions per year; approximately 70% of patients receive neuroleptics. Thus, if our experience is typical of others, we would expect about 15 cases of NMS yearly. In fact, this prediction appears to be consistent with the experience of other groups [4,5]. Although various agents (e.g., amantadine, bromocriptine, and dantrolene) have been used in the therapy of NMS, the cornerstone of treatment remains prompt discontinuation of neuroleptics and intensive medical and nursing care [6,7]. From this perspective, one may ask whether an acute episode of NMS can be adequately treated in a freestanding psychiatric hospital. Consider the odyssey of one patient with NMS who was not accurately diagnosed despite evaluation by many well-trained physicians in four different hospitals [B]. The authors of this report made a plea for maintaining general medical personnel in inpatient psychiatric settings. They commented, “Today, when many of our hospitals for the mentally ill, at least in the public sector, are witnessing a major loss of trained medical personnel, the risk of potentially lethal NMS grows greater” [8, pp. 45-461. More to the point, Janati and Webb [9] observed that “because of the lability of the patient’s status, admission to an intensive care unit is essential” (p. 1570). In a review of 55 cases of NMS, Lavie et al. [lo] found that more than one third of patients did, in fact, require admission to intensive care units. Close medical monitoring and supportive treatment beyond that which can reasonably be pro245
ISSN 0163-8343/90/$3.50
A. Lazarus
vided in a private psychiatric hospital may be necessary for patients with NMS for several reasons. Multidisciplinary treatment is often necessary in the acute phase of NMS, and such treatment is more readily available in a general medical setting. Not infrequently, consultation is required with an internist, a critical-care specialist, a neurologist, or an anesthesiologist (if use of dantrolene is contemplated). Later in the course of therapy, physiotherapy and consultation with a physiatrist may be needed. In the event of rapid medical deterioration or serious complications, admission to an intensive care unit doesbecome essential. Highly specialized treatment, such as cardiac monitoring, renal dialysis, and respiratory ventilation, may be necessary. From a nursing standpoint, patients with NMS are also probably better monitored in a medical hospital [11,12]. Skilled nursing care outside the scope of that normally provided by psychiatric nurses may include complicated intravenous therapy, nasogastric tube feedings and maintenance, and specialized nursing care involved in the treatment of immobile patients to prevent thromboembolism and decubitus ulcers: assistance with ambulation, skin care, and body positioning. Clearly, monitoring for weight loss, fever, tachycardia, diaphoresis, muscular rigidity, and fluid intake and urinary output is more easily accomplished in a medical intensive setting. In one case of NMS that was initially misdiagnosed as catatonic schizophrenia, the correct diagnosis was made only after astute intensive care nurses pointed out that the patient appeared physically rather than mentally ill [13, and oral communication 19851. The inadequacy of private hospitals for many other neuropsychiatic conditions could also be questioned-advanced anorexia nervosa, delirium tremens, acute catatonic excitement-not to mention the many threatening medical conditions in geriatric psychiatry. Regrettably, the severity of medical illness may not be a significant factor in determining the locus of care of psychiatric patients [14]. However, implying that patients with NMS cannot be treated adequately in a freestanding psychiatric facility could be unduly alarmist, if not insulting to the staff of those facilities that do have strong primary medical skills and collaborative consulting relationships. Furthermore, it is recognized that not all cases of NMS are severe enough to warrant a blanket recommendation for treatment in a medical hospital. Some cases may be mild in that they may not show severe rigidity and hy246
perthermia, and symptoms may abate in the face of ongoing neuroleptic treatment [4]. The decision to transfer a psychiatric patient to a general medical hospital or an intensive care unit is one that is not made easily. Although a few studies have examined the transfer of patients from medical-surgical inpatient settings to psychiatric inpatient units [14,15], no studies have investigated the process in reverse, certainly not with respect to patients with NMS. The decision to transfer a psychiatric patient to a more intense medical setting appears to be made empirically depending on the severity and duration of medical complications, previous response to treatment, and the availability of facilities and personnel that would ensure proper medical care. Transfer to a general hospital is recommended when patients with NMS develop renal failure, cardiopulmonary failure, disseminated intravascular coagulation, aspiration pneumonia, widespread infection, pulmonary embolism, prolonged seizure activity, profound dehydration, or shock. Knowledgeable staff must be able to differentiate acute from chronic illness and understand adverse drug reactions and possible drug interactions [16]. They should be able to demonstrate skills in physical and laboratory assessment as well as technical skills such as insertion of intravenous lines, arterial lines and feeding tubes, administration of intravenous and hyperalimentation solutions, and use of intravenous pumps. Both medical and nursing staff should be well versed in procedures used in cardiac and respiratory arrest, including airway management, oxygen supplementation, interpretation of EKG, and other basic life support measures. Any facility treating patients suspected of having NMS should be able simultaneously to investigate other conditions resembling NMS, especially infectious, neurologic, and toxic-metabolic conditions [17]. This would include having provisions for chest xray, EKG, EEG, and routine blood and urine tests. A prompt check for abnormalities associated with NMS, for example, leukocytosis, elevated CPK, and myoglobinuria should be possible. Perhaps it is not a coincidence that no deaths were reported in a series of 20 patients afflicted with 24 episodes of NMS when they were treated in a general hospital with vigorous supportive therapy [7]. Likewise, a recent study [18] of over 200 published reports of NMS indicated that although mortality from NMS has been steadily declining, a positive outcome is not necessarily related to therapy with dopaminergic agents and dantrolene.
Neuroleptic
These studies suggest there is increased medical morbidity when intensive supportive care is unavailable.
References 1. Lazarus
2. 3.
4.
5.
6.
7.
8.
A, Mann SC, Caroff SN: The Neuroleptic Malignant Syndrome and Related Conditions. Washington, DC, American Psychiatric Press, 1989 Caroff SN: The neuroleptic malignant syndrome. J Clin Psychiatry 41:79-83, 1980 Sakkas P, Davis JM, Jin H: Vulnerability and presentation of NMS. Presented at the 142nd annual meeting of the American Psychiatric Association, San Francisco, May 9, 1989 (new research abstract) Addonizio G, Susman VL, Roth SD: Symptoms of neuroleptic malignant syndrome in 82 consecutive inpatients. Am J Psychiatry 143:1587-1590, 1986 Keck PE Jr, Pope HG Jr, McElroy SL: Frequency and presentation of neuroleptic malignant syndrome: A prospective study. Am J Psychiatry 1441344-1346, 1987 Kaufmann CA, Wyatt RJ: Neuroleptic malignant syndrome. In Meltzer HY (ed), Psychopharmacology: The Third Generation of Progress. New York, Raven Press, 1987, pp. 1421-1430 Rosebush P, Stewart T: A prospective analysis of 24 episodes of neuroleptic malignant syndrome. Am J Psychiatry 146:717-725, 1989 Ingraham MR, Joo CJ, Tovin K: Neuroleptic malignant syndrome: A case report. Int J Psychiatry Med 12:43-47, 1982
Malignant
Syndrome
9. Janati A, Webb RT: Successful treatment of neuroleptic malignant syndrome with bromocriptine. South Med J 79:1567-1571, 1986 10. Lavie CJ, Olmstead TR, Ventura HO, Lepler BJ: Neuroleptic malignant syndrome: An underdiagnosed reaction to neuroleptic agents? Postgrad Med 80:171178, 1986 11. Cahill C, Arana GW: Navigating neuroleptic malignant syndrome. Am J Nurs 86:671-673, 1986 12. Keltner NL, McIntyre CW: Neuroleptic malignant syndrome. J Neurosurg Nurs 17:362-366, 1985 13. Weinberger DR, Kelly MJ: Catatonia and malignant syndrome: A possible complication of neuroleptic administration. J Nerv Ment Dis 165:263-268, 1977 14. Leibenluft E, Goldberg RL, Miller J, et al: Who gets treated where: A study of patients transferred and not transferred from a consultation-liaison service to a general hospital psychiatry unit. Gen Hosp Psychiatry 11:182-186, 1989 15. Weimer SR, Fenn HH: Patient transfers from medical and surgical settings to psychiatric inpatient wards. Gen Hosp Psychiatry 4:179-185, 1982 16. Cowart T, Stoudemire A: Nursing staff development and facility design for medical-psychiatry units. Gen Hosp Psychiatry 11:36-47, 1989 17. Vinogradov S, Brody S, Csernasky JG, et al: Consultation in clinical psychopharmacology: Neuroleptic malignant syndrome. Hosp Formul 23:646-653, 1988 18. Shalev A, Hermesh H, Munitz H: Mortality from neuroleptic malignant syndrome. J Clin Psychiatry 50:18-25, 1989
247