Abstract
We herein report our experience with anesthetic management of a schizophrenic patient with a medical history of neuroleptic malignant syndrome (NMS).
A 48-yr-old man with an old (chronic) bilateral luxation of the temporomandiblar joints was scheduled for bilateral eminoplasty. He had been diagnosed with schizophrenia at the age of 42, and suffered NMS twice during psychotropic drug therapy. Each time he was treated by terminating his psychotropic drugs, hypothermic therapy and administration of bromocriptine mesilate, leading to a recovery from NMS within two to three weeks. He demonstrated involuntary bilateral finger movement, dorsiflexion of soma and retroflexion of the collum, but no hallucination and phantasm preoperatively. The results of laboratory tests were unremarkable. Medication administered to the patient preoperatively was continued until the day of surgery. No other pre-medication was used.
Anesthesia was induced with 100mg of propofol and 8mg of vecuronium bromide to facilitate nasotracheal intubation, and maintained with sevoflurane, nitrous oxide and oxygen. Barbiturates were avoided as an induction agent due to their potentiality in the causation of circulatory depression from drug interactions with psychotropic drugs. Succinylcholine was avoided as a muscle relaxant for possible risk of causing malignant hyperthermia; i. e. a condition similar to that observed in neuroleptic malignant syndrome (NMS). A radial arterial catheter and a subclavian venous catheter were inserted and the direct arterial pressure and central venous pressure were monitored with a standard anesthetic monitor. The anesthetic course was uneventful (SpO2: 96-98%; rectal temperature: 36.8-37.9°C; heart rate: 70-92 beats/min; systolic blood pressure: 98-115mmHg; diastolic pressure: 55-70mmHg). The record is shown in Figure 1. One mg of atropine sulphate and 2.5mg of vagostigmin were administered after confirmation of spontaneous respiration. The patient was extubated after awakening, which was confirmed by opening of the eyes and movement of the extremities. The amount of blood loss (quantity of bleeding) was 64g, surgical time was 2 hours 38 minutes, and the anesthesia time was 5 hours. After surgery, the blood pressure, heart rate, SpO2 and body temperature were monitored every four hours for 72 hours.
We were able to manage this patient without complications and occurrence of neuroleptic malignant syndrome (NMS) during the perioperative period.
