Propofol-remifentanil combination for management of electroconvulsive therapy in a patient with neuroleptic malignant syndrome.
ABSTRACT Electroconvulsive therapy can be effective in severe or treatment resistant neuroleptic malignant syndrome patients. Anesthesia and use of muscle relaxant agents for electroconvulsive therapy in such patients may encounter anesthesiologists with specific challenges. This case report describes successful management of anesthesia in 28-year-old male patient undergoing eight electroconvulsive therapy sessions for treatment of neuroleptic malignant syndrome.
- Anesthesiology 09/1999; 91(2):574-5. · 5.16 Impact Factor
Article: Neuroleptic malignant syndrome.BJA British Journal of Anaesthesia 08/2000; 85(1):129-35. · 4.24 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The present visual and electromyographic study was designed to evaluate muscle fasciculations caused by succinylcholine in adults pretreated with either remifentanil 1.5 microg/kg or saline. The effect of remifentanil on succinylcholine-induced muscle fasciculations was studied using a double-blind method in 40 adults. After i.v. pretreatment with either remifentanil 1.5 microg/kg (remifentanil group, n = 20) or an equivalent volume of i.v. saline (saline group, n = 20), patients were anaesthetized with a 2.0 mg/kg of i.v. propofol followed by i.v. succinylcholine 1.0 mg/kg. Intensity and duration of muscle fasciculation following i.v. succinylcholine administration were recorded. Electromyography (EMG) was used to quantify the extent of muscle fasciculation following i.v. succinylcholine injection. Myalgia was evaluated 24 hours after induction time. Serum potassium levels were measured five minutes after i.v. succinylcholine administration and creatine kinase (CK) levels 24 hours after induction time. Compared to saline treated controls, remifentanil decreased the intensity of muscle fasciculations caused by i.v. succinylcholine [fasciculation severity scores (grade 0 to 3) were 2/1/12/5 and 3/13/4/0 (patients numbers) in the saline group and the remifentanil group, respectively, p < 0.001]. The mean (SD) maximum amplitude of muscle action potential (MAP) by EMG was smaller in the remifentanil group [283.0 (74.4) microV] than in the saline group [1480.4 (161.3) microV] (p = 0.003). Postoperative serum CK levels were lower in the remifentanil group (p < 0.001). Postoperative myalgia was not different between the two groups. Remifentanil 1.5 microg/kg attenuated intensity of muscle fasciculations by succinylcholine.Yonsei medical journal 07/2010; 51(4):585-9. · 0.77 Impact Factor
Hindawi Publishing Corporation
Case Reports in Medicine
Volume 2012, Article ID 585713, 3 pages
Management of ElectroconvulsiveTherapy ina Patient with
1Department of Psychiatry, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
2Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran
3Department of Anesthesia, Kurdistan University of Medical Sciences, Beasat Hospital, Sanandaj, Iran
Correspondence should be addressed to Karim Nasseri, nasseri firstname.lastname@example.org
Received 17 November 2011; Accepted 22 January 2012
Academic Editor: S. Kennedy
Copyright © 2012 Modabber Arasteh et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Electroconvulsive therapy can be effective in severe or treatment resistant neuroleptic malignant syndrome patients. Anesthesia
and use of muscle relaxant agents for electroconvulsive therapy in such patients may encounter anesthesiologists with specific
challenges. This case report describes successful management of anesthesia in 28-year-old male patient undergoing eight
electroconvulsive therapy sessions for treatment of neuroleptic malignant syndrome.
Neuroleptic malignant syndrome (NMS) is a rare, unpre-
dictable, and potentially fatal complication of certain anti-
psychotic medications. The incidence and mortality rates
of NMS are approximately 0.07% to 2.2%, and 15%–25%,
respectively . Typical characteristics consist of hyperther-
mia, altered level of conscious, muscle rigidity, catatonia,
autonomic dysfunction, and elevation of Creatine Kinase
(CK) level. All the previous findings are not necessary
for diagnosis . Bromocriptine, dantrolene, and benzodi-
azepines are effective in the treatment of NMS [2, 3]. Some
authors recommend that electroconvulsive therapy (ECT)
may be effective if signs and symptoms are resistant to
supportive care and pharmacotherapy [4, 5].
There are a known sameness between the clinical symp-
toms of NMS and malignant hyperthermia (MH) ; there-
fore several reports have incited some controversy regarding
the safety of the use of known triggering agents of MH
such as succinylcholine in patients with a history of NMS
[6–8]. Anesthesia and muscle relaxation for ECT in such
patients poses specific challenges to anesthesiologists. This
case report describes successful use of propofol-remifentanil
without muscle relaxant in a patient undergoing ECT for the
treatment of NMS.
A 28-year-old male with a history of bipolar mood disorder
and moderate mental retardation was admitted to hos-
pital with increasing body temperature, muscle rigidity,
diaphoresis, cognitive impairment, and some degrees of
impaired consciousness. He had been taking thioridazine
and valproate for a period of 6 months prior to hospital
admission. On examination the patient was mute and
signs were as follows: temperature (38.2◦C), blood pressure
131/82mmHg, heart rate 114beats/min, and respiratory
rate 18. The CK level was markedly elevated (1245U/L)
other laboratory results, including electrolytes, were slightly
elevated. He had several psychiatric hospitalizations, during
the last years prior to the present episode, and lived
in a chronic mental disorder institute. In family history
his monozygotic twin had died with NMS manifestations
about one year ago. Antipsychotic drugs were stopped, and
diagnosis of NMS was made, because the patient met three
2 Case Reports in Medicine
major (rigidity, hyperthermia, rising of CK) and three minor
criteria (tachycardia, diaphoresis, cognitive impairment) of
NMS. After six days because of progressive catatonia and
muscular rigidity ECT under anesthesia was considered.
After preoxygenation with 100% O2 via face mask,
anesthesia was induced with remifentanil 1.5µg/kg and
propofol 1.5mg/kg IV slowly. Then the ECT stimulus was
applied, and it produced an ensuing seizure. Succinylcholine
and any other muscle relaxants were avoided. The doses of
of ECT and there was no need for adding other anesthetic
or analgesic drugs for inducing anesthesia. Bilateral ECT
was administered using an ECT stimulator (brief pulse rate,
analog-output ECT: type RF class 1. ARA 121; ARA Co
Ltd., Tehran, Iran). The first selected stimulus intensity was
20% that induced a 32-second relatively tense seizure. The
stimulus intensity titrated based on previous seizure length
and reached 50% in the last session. The range of seizure
duration was 24–37 second (mean 27 second). The mean
time from inducing anesthesia to returning spontaneous
ventilation was 8 minutes [7–10], and patient opened his
eyes by commend after 9–14 minutes (mean 11 minutes).
The body temperature was measured on several occasions
following ECT, at intervals of 3-4hour. We did not observe
any changes in body temperature. After eight ECT sessions
that was done three times a week, the psychotic symptoms
improved considerably, CK level turned back toward normal
ranges slightly, and the patient was discharged from hospital
without further complications.
Although NMS and MH result from different pathophysio-
clinical features. So patients susceptible to NMS may be
vulnerable to developing MH. ECT has been used as a treat-
ment for NMS, because it supposedly increases circulating
catecholamines, including dopamine, in the central nervous
system [2, 3].
Succinylcholine remains the most commonly used mus-
cle relaxant to decrease the strong muscle contractions
associated with ECT-induced seizure activity . However,
the use of this rapid and short-acting drug can accompany
with side effects in patients with history of susceptibility
to MH, NMS, and catatonic schizophrenia [11, 12]. And it
has been suggested that the use of succinylcholine should be
avoided in patients with a history of these diseases .
Although nondepolarizing agents has been used success-
fully in the treatment of NMS, some authors suggest that
these drugs are associated with increases in temperature,
CK levels, and leukocytosis  too, so it may be advisable
to avoid administering depolarizing and nondepolarizing
muscle relaxants to patients with NMS. Based on this
propofol without muscle relaxant in this case. In the sole
related case report that we find, Franks et al.  performed
ECT on an MH susceptible patient using thiamylal without
during the seizure and experienced severe muscle pain after
Remifentanil is an ultra-short-acting opioid with a rapid
onset and an ultrashort context sensitive half-time .
Propofol has significant myorelaxant properties on pharyn-
geal and laryngeal structures, so it is the agent of choice
for intubation without muscle relaxant . On the other
hand, there are some reports that the infusion of propofol
and remifentanil slightly decrease both the train-of four
ratio in comparison with the preoperative value  and
succinylcholine-induced fasciculation [19, 20]. Based on the
results reported herein, and the aforementioned pharmaco-
general anesthesia using remifentanil-propofol boluses with-
out neuromuscular blocking agents and were able to com-
plete sessions of ECT without any associated complications.
muscle relaxants for ECT in NMS patients is safe and effec-
 Y. Asakura, Y. Fujiwara, and T. Komatsu, “The WHO analgesic
ladder and neuroleptic malignant syndrome,” Acta Anaesthesi-
ologica Scandinavica, vol. 50, no. 10, pp. 1311–1312, 2006.
 S. N. Caroff, “Neuroleptic malignant syndrome,” in Neurolep-
tic Malignant Syndrome and Related Conditions, S. C. Mann,
S. N. Caroff, P. E. Keck Jr, and A. Lazarus, Eds., pp. 1–44,
American Psychiatric Publishing, Washington, DC, USA, 2nd
 P. Sakkas, J. M. Davis, P. G. Janicak, and Z. Wang, “Drug
treatment of the neuroleptic malignant syndrome,” Psy-
chopharmacology Bulletin, vol. 27, no. 3, pp. 381–384, 1991.
 F. Ozer, H. Meral, B. Aydin, L. Hanoglu, T. Aydemir, and T.
Oral, “Electroconvulsive therapy in drug-induced psychiatric
states and neuroleptic malignant syndrome,” Journal of ECT,
vol. 21, no. 2, pp. 125–127, 2005.
 J. R. Strawn, P. E. Keck, and S. N. Caroff, “Neuroleptic
no. 6, pp. 870–876, 2007.
 K. J. McAllen and D. R. Schwartz, “Adverse drug reactions
resulting in hyperthermia in the intensive care unit,” Critical
Care Medicine, vol. 38, no. 6, pp. S244–S252, 2010.
 S. N. Caroff, H. Rosenberg, J. E. Fletcher, T. D. Heiman-
bility in neuroleptic malignant syndrome,” Anesthesiology, vol.
67, no. 1, pp. 20–25, 1987.
 H. C. A. Silva, V. S. Bahia, R. A. A. Oliveira, P. E. Marchiori,
M. Scaff, and A. M. C. Tsanaclis, “Malignant hyperthermia
susceptibility in three patients with malignant neuroleptic
syndrome,” Arquivos de Neuro-Psiquiatria, vol. 58, no. 3, pp.
 A. Lazarus and H. Rosenberg, “Malignant hyperthermia
during ECT,” American Journal of Psychiatry, vol. 148, no. 4,
pp. 541–542, 1991.
 P. Adnet, P. Lestavel, and R. Krivosic-Horber, “Neuroleptic
malignant syndrome,” British Journal of Anaesthesia, vol. 85,
no. 1, pp. 129–135, 2000.
Case Reports in Medicine3
 R. C. Cooper, P. L. Baumann, and W. M. McDonald,
“An unexpected hyperkalemic response to succinylcholine
during electroconvulsive therapy for catatonic schizophrenia,”
Anesthesiology, vol. 91, no. 2, pp. 574–575, 1999.
 E. Kelly and S. J. Brull, “Neuroleptic malignant syndrome and
mivacurium: a safe alternative to succinylcholine?” Canadian
Journal of Anaesthesia, vol. 41, no. 9, pp. 845–849, 1994.
 H. Hermesh, D. Aizenberg, M. Lapidot, and H. Munitz, “The
malignant syndrome,” Anesthesiology, vol. 70, no. 1, pp. 171–
 S. A. Vitkun, R. V. Boccio, and P. J. Poppers, “Anesthetic man-
agement of a patient with neuroleptic malignant syndrome,”
Journal of Clinical Anesthesia, vol. 2, no. 3, pp. 188–191, 1990.
 R. D. Franks, B. Aoueille, M. C. Mahowald, and N. Masson,
“ECT use for a patient with malignant hyperthermia,” Ameri-
can Journal of Psychiatry, vol. 139, no. 8, pp. 1065–1066, 1982.
 S. Grant, S. Noble, A. Woods, J. Murdoch, and A. Davidson,
“Assessment of intubating conditions in adults after induction
with propofol and varying doses of remifentanil,” British
Journal of Anaesthesia, vol. 81, no. 4, pp. 540–543, 1998.
 K. McKeating, I. M. Bali, and J. W. Dundee, “The effects
of thiopentone and propofol on upper airway integrity,”
Anaesthesia, vol. 43, no. 8, pp. 638–640, 1988.
 D. Lee, K. C. Lee, J. Y. Kim, Y. S. Park, and Y. J. Chang, “Total
intravenous anesthesia without muscle relaxant in a patient
with amyotrophic lateral sclerosis,” Journal of Anesthesia, vol.
22, no. 4, pp. 443–445, 2008.
 K. Nasseri, M. T. Arastheh, and S. Shami, “Pretreatment with
remifentanil is associated with less succinylcholine-induced
fasciculation,” Middle East Journal of Anesthesiology, vol. 20,
no. 4, pp. 515–520, 2010.
 M. J. Yun, Y. H. Kim, Y. K. Go et al., “Remifentanil
attenuates muscle fasciculations by succinylcholine,” Yonsei
Medical Journal, vol. 51, no. 4, pp. 585–589, 2010.