Neuroleptic malignant syndrome associated with haloperidol use in critical care setting: should haloperidol still be considered the drug of choice for the management of delirium in the critical care setting?

Perioperative utility of amisulpride and dopamine receptor antagonist antiemetics-a narrative review

Despite advances in antiemetics and protocolized postoperative nausea vomiting (PONV) management, it remains one of the most common postoperative adverse events. In patients who developed PONV despite antiemetic prophylaxis, giving a rescue treatment from the same class of medication is known to be of limited efficacy. Given the widespread use of 5-HT3 antagonists as PONV prophylaxis, another class of effective intravenous rescue antiemetic is in dire need, especially when prophylaxis fails, and rescue medication is utilized. Dopamine antagonists were widely used for the treatment of PONV but have fallen out of favor due to some of their side effect profiles. Amisulpride was first designed as an antipsychotic medication but was found to have antiemetic properties. Here we will review the historical perspective on the use of dopamine receptor antagonist antiemetics, as well as the evidence on the efficacy and safety of amisulpride.

Development of Atypical Neuroleptic Malignant Syndrome After Treatment of Cocaine Intoxication: A Case Report and Literature Review

Neuroleptic malignant syndrome (NMS) is a life-threatening condition classically associated with the use of antipsychotic medications. NMS commonly presents with initial mental status changes, followed by muscle rigidity, fever, and eventual dysautonomia. Cocaine intoxication can present with symptoms that are very similar to those found in NMS, making differentiating the two disorders challenging. We present the case of a 28-year-old female with a history of cocaine use disorder who presented with acute cocaine intoxication. She had severe agitation associated with her intoxication, requiring the use of antipsychotic medications. Subsequently, she developed atypical NMS from abrupt dopamine withdrawal after receiving the antipsychotics. Although overlapping dopamine pathways between cocaine use and NMS could deter one from this practice and guidelines recommend against it, antipsychotics are routinely used in the emergency setting for cocaine-associated agitation. This case highlights the need for a more standardized treatment protocol, provides an explanation of why treating cocaine intoxication with antipsychotics is inappropriate, and suggests that chronic cocaine users may be more prone to NMS in this scenario. Furthermore, this is a unique case because it describes atypical NMS in the context of cocaine intoxication, chronic cocaine use, and administration of antipsychotics to an antipsychotic-naïve patient.

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

BACKGROUND

Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available.

OBJECTIVES

The aim of this study was to ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS.

METHODS

We did a population-based study using data from the Hong Kong Hospital Authority's Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91-120 days before the index date. To adjust for potential time trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications and acute medical conditions.

RESULTS

297,647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time trend, and case-crossover adjusted for time trend and potential confounders analysis were 8.00 (95% confidence interval 3.42-18.69), 5.88 (2.46-14.04), and 4.77 (1.95-11.66).

CONCLUSIONS

Our results suggest that recent use of antipsychotics is associated with NMS. Although a case-only design inherently controls for confounding by time-invariant factors, residual confounding by acute medical conditions with similar presentations to NMS cannot be fully excluded.

Thermoregulation and age

The thermoregulatory functions may vary with age. Thermosensitivity is active in neonates and children; both heat production and heat loss effector mechanisms are functional but easily exhaustable. Proportional and lasting defense against thermal challenges is difficult, and both hypothermia and hyperthermia may easily develop. Febrile or hypothermic responses to infections or endotoxin can also develop, together with confusion. In small children febrile convulsions may be dangerous. In old age the resting body temperature may be lower than in young adults. Further, thermosensitivity decreases, the thresholds for activating skin vasomotor and evaporative responses or metabolism are shifted, and responses to thermal challenges are delayed or insufficient: both hypothermia and hyperthermia may develop easily. Infection-induced fevers are often limited or absent, or replaced by hypothermia. Various types of brain damage may induce special forms of hypothermia, hyperthermia, or severe fever. Impaired mental state often accompanies hypothermia and hyperthermia, and may occasionally be a dominant feature of infection (instead of the most commonly observed fever). Aging brings about a turning point in women's life: the menopause. The well-known influence of regular hormonal cycles on the thermoregulation of a woman of fertile age gives way to menopausal hot flushes caused by estrogen withdrawal. Not all details of this thermoregulatory anomaly are fully understood yet.