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Neuroleptic malignancy syndrome

neuroleptic malignancy syndrome

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Neuroleptic malignancy syndrome

  1. 1. 抗精神病藥惡性症候群 Neuroleptic Malignant Syndrome 加護病房查房日誌
  2. 2. 抗精神病藥物惡性症候群 (Neuroleptic Malignant Syndrome, NMS) • 發生率低(0.02-3%) ,但有致死性風險 – 1960年代死亡率76%掉到近期10-20% • 與使用抗精神病藥物相關 • 臨床症狀 – 意識改變 – 肌肉僵硬 – 發燒 – 自主神經失調 文獻: Eelco FM. Neuroleptic malignant syndrome. In: UpToDate, Janet LW (Ed), UpToDate, Waltham, MA. (Accessed on Sep 12, 2014.)
  3. 3. 病理學 • 原因未明 • 主要認為和在下視丘的dopamine receptor blockade有關 – 導致高溫和自主神經失調 • 影響nigrostriatal dopamine pathways或直接影響肌 肉粒腺體功能 – 導致肌肉僵硬和顫抖 文獻: Eelco FM. Neuroleptic malignant syndrome. In: UpToDate, Janet LW (Ed), UpToDate, Waltham, MA. (Accessed on Sep 12, 2014.)
  4. 4. Neuroleptic Malignant Syndrome相關藥物 抗精神病藥物 • Aripiprazole • Clozapine • Haloperidol • Olanzapine • Paliperidone • Quetiapine • Risperidone • Ziprasidone 止吐藥物 • Domperidone • Metoclopramide • Prochlorperazine • Promethazine 通常發生在用藥的前兩周 有可能一個劑量或好幾年後產生 與劑量不一定相關 抗帕金森藥物戒斷
  5. 5. 四大臨床症狀 精神症狀的改變 肌肉呈現剛性 發燒 (>40度C) 自主神經機能障礙
  6. 6. 檢驗數據 • 血清中creatine kinase(CK)上升 – 1000-100,000 IU/L – 肌肉僵硬 – 與疾病嚴重度和預後有關 – NMS結束後會恢復 • 其它常見但非特異 – 白血球增加、輕度增加lactate dehydrogenase/ alkaline phosphatase/liver transaminases、電解 質異常 文獻: Eelco FM. Neuroleptic malignant syndrome. In: UpToDate, Janet LW (Ed), UpToDate, Waltham, MA. (Accessed on Sep 12, 2014.)
  7. 7. 鑑別診斷 相關疾病 • Serotonin syndrome • Malignant hyperthermia • Malignant catatonia • Other drug-related syndromes 非相關疾病 • Central nervous system infection • Systemic infections • Seizures • Acute hydrocephalus • Acute spinal cord injury • Heat stroke • Tetanus 文獻: Eelco FM. Neuroleptic malignant syndrome. In: UpToDate, Janet LW (Ed), UpToDate, Waltham, MA. (Accessed on Sep 12, 2014.)
  8. 8. 診斷 • 無特定診斷檢驗 • 典型的檢驗值不正常可幫忙確認臨床診斷 • 需檢驗來排除其它情況 – 腦部影像檢查和腰錐穿刺 – 腦波檢查 文獻: Eelco FM. Neuroleptic malignant syndrome. In: UpToDate, Janet LW (Ed), UpToDate, Waltham, MA. (Accessed on Sep 12, 2014.)
  9. 9. Neuroleptic Malignant Syndrome治療 • 停用可能藥物 • 支持療法 • CK高,給大量水分和鹼化尿液(sodium bicarbonate): 避免橫紋肌溶解造成之急性腎 衰竭 • 退燒: 冰枕等,藥物: acetaminophen/aspirin • BZD(clonazepam/lorazepam)控制躁動 • 降血壓: clonidine/nitroprusside • Heparin 預防DVT
  10. 10. 藥物治療-1 • Dantrolene – 直接骨骼肌鬆弛劑,劑量1-2.5 mg/kg IV ,最大 劑量10 mg/kg/day – 最快幾分鐘就有效,用10天內慢慢停用 – 肝毒性 • Bromocriptine – Dopamine agonist ,劑量2.5 mg q6-8h ,最大劑 量40 mg/day ,用10天慢慢停用
  11. 11. 藥物治療-2 • Amantadine – Dopaminergic 和anticholinergic效果 bromocriptine的替代藥物,100 mg q12h ,最大 劑量200 mg q12h • 其它藥物 – Levodopa, apomorphine, carbamazepine 和 benzodiazepines (lorazepam, clonazepam)
  12. 12. 藥物比較 藥名 恢復時間 死亡率 健保 單獨支持療法 15天 21% -- Dantrolene 9天 8.6% 5000 元/瓶 Bromocriptine 10天 7.8% 8.1 元 /顆 Amantadine -- 5.9% 8.5 元/顆 文獻 Arch Intern Med 1989;149:1927 Psychopharmacol Bull 1991;27:381
  13. 13. 避免橫紋肌溶解造成之急性腎衰竭-1 • UpToDate建議 – Creatinine kinase (CK) > 5000 unit/L – 就要給予輸液 (Grade 1B) • 理想輸液選擇未定論: – UpToDate建議生理食鹽水 (Grade2C) • 理想流速未定論: – UpToDate建議1-2 L/hr (Grade2C) – 調整流速至預期的尿量(200-300 ml/hr) 文獻: Joseph AE. Prevention treatment of heme pigment-induced acute kidney injury and . In: UpToDate, Alice MS (Ed), UpToDate, Waltham, MA. (Accessed on Nov 12, 2014.)
  14. 14. 避免橫紋肌溶解造成之急性腎衰竭-2 • 鹼化尿液: – 缺乏實證證明對嚴重橫紋肌溶解有好處 • 無尿病人可能引起嚴重鹼中毒 • UpToDate建議: – 給予鹼性溶液條件: » 給有排尿,無嚴重低血鈣,動脈pH<7.5, HCO3- < 30 mEq/L的病人 (Grade2C) – 停用條件 » 若3-4小時,pH尚未高於6.5 » pH增加到7.5, HCO3- > 30 ,或有症狀的低血鈣 文獻: Joseph AE. Prevention treatment of heme pigment-induced acute kidney injury and . In: UpToDate, Alice MS (Ed), UpToDate, Waltham, MA. (Accessed on Nov 12, 2014.)
  15. 15. 避免橫紋肌溶解造成之急性腎衰竭-3 • Loop diuretics亦無文獻證明可預防 – 但若於體液過多的病人可用 • 要監測血鉀和鈣離子 – 高血鉀或低血鈣則必須治療 • 也許需要洗腎 – 矯正高血鉀和體液過多等問題 文獻: Joseph AE. Prevention treatment of heme pigment-induced acute kidney injury and . In: UpToDate, Alice MS (Ed), UpToDate, Waltham, MA. (Accessed on Nov 12, 2014.)
  16. 16. 感恩聆聽 16

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neuroleptic malignancy syndrome

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