Joliet Junior College Neuroleptic Malignant Syndrome Essay

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Brian Keogh and Louise Doyle provide mental health nurses with guidance on recognising and managing potentially fatal adverse effects of a range of medications T keywords > drugs: adverse reactions > psychiatric disorders: drug therapy These iceywords are based on the subject headings from the British Nursing Index, This article has been subject to a double-blind review. here have been many advances in the care of people with mental health problemsin recent years. Those at the forefront of the changes have called for a reduction in the emphasis on medication-based treatments and for the introduction of more interventions based on a psychosocial approach. Despite this, psychopharmacology remains the main treatment for most people in mental distress. The role of the mental health nurse in the administration of medications has become increasingly complex, given the range of preparations available and their potential to induce adverse and toxic effects in susceptible individuals. Recognising the adverse and toxic effects of psychopharmacology is a key part of the mental heaith nurse’s role and involves assisting individuals to manage side effects which may impact on their quality of life. Occasionally, medications used in contemporary psychiatry can induce potentially lifethreatening adverse reactions in a small number of individuals. Given the idiosyncratic nature of some of these effects, and the difficulty in predicting people who are vulnerable, early 28 mental health practice march 2008 vol 11 no 6 recognition and intervention is imperative to a successful outcome should these occur. Agranulocytosi5 Agranulocytosis is a blood disorder (dyscrasia) characterised by a selective reduction in white blood cells, particularly neutrophils, resulting in an increased susceptibility to infection in those affected (Downie ef ai 2004), Rosenfeld and Loose-Mitchell (1998) suggest that blood disorders are relatively rare for clients taking anti psychotic drugs, except in the case of clozapine which may induce agranuiocytosis in up to 3 per cent of individuals taking the drug, Clozapine is classed as an atypical anti psychotic drug which is indicated in the treatment of resistant schizophrenia. Although its side effect profile is similar to conventional | anti psychotics, clozapine’s potential to induce agranulo-1 cytosis caused its removal from production in the 1970s, It t was reintroduced in the 1990s and can only be prescribed ^’ under strict supervision by the Clo2apine Patient Monitoring 5- Service. Individuals prescribed the drug must have a blood test to ensure that agranulocytosis has not occurred, then a weekly blood test for the first 18 weeks, fortnightly for up to a year, and then monthly thereafter (Healy 2005), Agranulocytosis is difficult to detect and is usually discovered when symptoms of infection appear. These symptoms include a raised temperature, sore throat and mucosal ulcers. Nurses need to watch out for these symptoms in patients taking clozapine and intervene accordingly. When detected early, intervention should only require the drug to be stopped and for symptomatic treatments to be given, such as for a sore throat or raised temperature. People who continue on anti psychotic medication, especially clozapine, after discharge from hospital should also be aware of this side effect and what to do if it occurs. Once agranucytosis has been detected, the individual’s condition should be monitored closely There is spontaneous recovery for most people within about two weeks (Downie etal 2004), mental status, fever and altered autonomic function. However, these symptoms could be indicative of changes to the client’s mental health or could have an alternative medical cause. Immediate discontinuation of the antipsychotic is essential. Pharmacological interventions include the possible use of a dopamine agonist such as bromocriptine to increase the production of dopamine and/or a muscle relaxant such as dantrolene (BNF 2007). In conjunction with this, antipyretics such as paracetamol can be given to reduce fever if indicated, Electroconvulsive therapy (ECT) may produce a rapid response to NMS and may also be beneficial for the underlying psychiatric condition (Pelonero era/1998, Healy 2005), Because of the idiosyncratic nature of NMS, prevention can be difficult as it is rarely possible to accurately predict who will develop the syndrome, Pelonero eta/(1998) identify that agitation, dehydration and a prior history of NMS are risk factors to the development of the syndrome. Therefore nurses should be familiar with a client’s previous reaction to antipsychotic medication and be aware of and respond Neuroieptic malignant syndrome Neuroleptic malignant syndrome (NMS) Is a potentially life to deficits in fluid balance in clients taking antipsychotic threatening, but relatively rare, idiosyncratic reaction to medications. neuroleptic medications. It is generally more likely to occur following the administration of high potency/low dose typical Nursing care ‘ antipsychotic such as haloperidol. However, it can occur in Apart from pharmacological interventions, the main course of response to any neuroleptic medication and in some cases treatment for NMS is symptomatic management, A cooling it can occur when the client is receiving antidepressants blanket and/or a fan may be required to help reduce pyrexia. (Galbraith era/2007). Clients with NMS should be cared for in a high observation It also occurs more frequently in those who are on higher area as their physical and mental condition needs to be doses of antipsychotic medications and where polypharmacy monitored closely. Routine observations should be taken regularly and documented, with anomalies reported to the responsible medical practitioner. The client may need assistAgranulocytosis ance with activities of daily living, as well as careful use of (pictured left) appropriate interpersonal skills such reality reorientation if confusion exists. Intravenous fluids may also be needed to Individuals prescribed clozapine must have correct dehydration and electrolyte abnormalities. a blood test to eliminate agranulocytosis weekly for the first 18 weeks, fortnightly for up to a year after this initial period and then monthly thereafter Attention to nutritional support is required as many clients may not be able to eat or drink due to altered mental status. The syndrome, which usually lasts for five to seven days after drug discontinuation, may be unduly prolonged if depot antipsychotics have been used. Where possible, clients with a history of NMS should not be given antipoccurs (Healy 2005). Many clients wiil experience NMS sychotic therapy again, and should instead be prescribed shortly after initial exposure to antipsychotic medications, alternative medications such as lithium, carbamazepine or and almost all clients who develop it do so within two weeks benzodiazepines. However, this may not always be posof commencing antipsychotic medications. However, it can sible and in these cases the client should be switched to also develop in clients who have taken anti psychotics over a an antipsychotic in a different class and with a lower D2 long period of time. Diagnosis of NMS can be complicated affinity than the one which produced the NMS {for example, as it initially presents in a similar way to serotonin syndrome atypical antipsychotics). (discussed later in the article). The symptoms associated with NMS include: Serotonin syndrome LJ muscular rigidity known as ‘lead pipe’ rigidity Serotonin syndrome (SS) is a rare but life-threatening drug • tremor reaction caused by an excess of serotonin. In most cases it LJ hyperthermia is caused by a build up of serotonin which is caused when U urinary incontinence drugs which act on the serotonergic system are prescribed U altered mental status (for example, confusion) with other drugs that also work on this system (such as • altered autonomic function (for example, high or low selective serotonin reuptake inhibitors, (SSRIs), prescribed blood pressure, elevated or rapid pulse) with tricyclic medications). It is generally more likely to occur within the first 24 hours of taking the medication or after U elevated serum creatinine phosphokinase secondary to an increase/overdose in medication. As SSRIs are now the muscle breakdown first line treatment for people with depression, nurses must • elevated white blood cell count. be familiar with the signs, symptoms and management of this potentially life-threatening condition. Treatment and prevention Early detection is essential if severe NMS is to be prevented. The symptoms associated with SS include: However, early diagnosis can be made difficult if the cardinal J jerks and twitches (myoclonus) symptom of muscle rigidity is not clearly evident. Nurses LJ tremors of the tongue or fingers must be familiar with other key symptoms such as altered LJ shivering march 2008 vol 11 no 6 mental health practice 29 order to plan further interventions. No further lithium should raised temperature be administered and large volumes of intravenous isotonic sweating saline are usually prescribed (Healy 2005), In more severe confusion, agitation or restlessness cases, the client will need to be treated as an emergency tachycardia and may require haemodialysis (BNF 2007), hyperreflexia Individuals prescribed lithium require information about diarrhoea the drug’s actions, the side effects and intoxication and euphoria other specific information required to (Galbraith era/2007). assist the client to remain within his Knowledge and vigilant Before a diagnosis is made, at least or her therapeutic index (Downie et three major symptoms should be apparobservation for serious a/2004), This information should be ent and the client must be taking a adverse effects are essential provided in a manner that is congruent medication that affects the serotonergic with the client’s ability to understand, system. The main differential diagnosis if mental health nurses are and verbal information should be is NMS, as both conditions share many to recognise, intervene and reinforced with as much written inforfeatures. However, the presence of mation as possible. Clients receiving diarrhoea, the more rapid onset of prevent fatalities that may lithium should be encouraged to carry the disorder and the absence of ‘lead a ‘lithium card’ which explains how to be caused by a range of pipe’ rigidity can help to establish a take the drug, what to do if they miss diagnosis of SS (Birmes ef al 2003), medications a dose, side effects (including lithium In most cases, SS will resolve once toxicity) and what medications and the offending agent(s) have been illnesses alter serum levels. Other advice on the lithium card stopped. Supportive care is essential in the management should include: of SS, Intravenous fluids may be required and the nurse should monitor vital signs and urine output regularly. As J drink alcohol in small quantities only with NMS, hyperthermia can be managed by introducing J get advice from nursing, medical or pharmaceutical measures to reduce the high temperature (for example, practitioners before taking other medications and avoid cooling blankets, fans and so on). The client should also be some medications such as diuretics and non steroid anti encouraged to drink plenty of fluids. In more severe cases, inflammatory drugs such as brufen a serotonin antagonist such as cyproheptadine may be used J drink plenty of water (especially when hot or during to reduce serotonin levels, although the beneficial effects of exercise) and do not vary daily salt intake such medications are not firmly established. LJ if the client is a female, she should consult her medical practitioner before getting pregnant (Downie et al 2004), Lithium toxicity • Q U Q a • • Birmes P, Coppin, D, Schmitt. L, Lauque D (2003) Serotonin syndrome; a brief review, Canadian Medical Association Journal, 168. 11. 14391442, Lithium is a commonly used drug in the treatment and BNF (2007) British National prophylaxis of bipolar affective disorder and depression. It Formulary. London, BMJ has many adverse effects and contraindications but the most Publishing Group/RPS worrying is lithium toxicity, which can be fatal and should Publishing, be treated immediately. Lithium is well known for its narrow Downie G, MacKenzie therapeutic/toxic range and doses are adjusted to a serum J, Williams A (2004) lithium level of 0,4 – 1 mmol/litre (BNF 2007), Patients can Pharmacology and become toxic for a number of reasons: overdose (accidental or Medicines Management purposeful), dehydration, or infections – although in certain for Nurses. Edinburgh, instances the cause is unclear (Healy 2005). Toxic symptoms Churchill Uvinstone, can occur at serum levels of 1,5mmol/!itre and require emerGalbraith A, Bullock S, Manias E eta/(2007) gency treatment if levels are 2mmol/litre or above. Fundamentals of Pharmacology: An Applied Approach for Nursing and Health. London, Pearson Education. Recognising lithium toxicity The symptoms associated with lithium toxicity are: U nausea and vomiting 3 diarrhoea Healy D (2005) Psychiatric U tremor {Healy 2005), Drugs Explained. However in more serious cases symptoms include: Edinburgh, Churchtll • hyperf lexia Livingstone, LJ hyperextension of limbs Pelonero AL. Levenson JL. LJ convulsions Pandurangi AK(1998) Neuroleptic malignant • toxic psychoses syndrome: a review. L3 syncope Psychiatric Services. 49, J renal failure 9,1153-1172, G circulatory failure Prosser S. Worster B, • coma (BNF 2007). MacGregorJ et al (2000) Applied Pharmacology. London, Harcourt Publishers. Rosenfeld G, LooseMitchell S (1998) Pharmacology (3rd edn), Philadelphia, Lippincott Williams S Wilkins, Treatment and prevention Treatment is dependent on the seriousness of the toxicity and careful observation is required by the nurse and the individual to recognise symptoms early and to intervene accordingly A doctor should review the client immediately and blood serum levels should be taken to ascertain the client’s condition in 30 mental health practice march 2008 vol U no 6 Clients must also be assessed for their motivation to take the drug and to attend for regular serum lithium levels and thyroid and renal function tests (Prosser ef al 2000), Those taking lithium should be advised to contact their community mental health nurse, pharmacist or GP if they have any queries or worries about lithium. They should also be aware of the symptoms of lithium toxicity and be advised to get medical help if they are feeling unwell, regardless of the cause. Conclusion The administration of medications is an integral part of the mental health nurses’ roles and in doing so they have a responsibility to be familiar with the preparations they administer. Imperative to this role is the careful observation of the medication’s effects and side effects, as well as educating clients to manage their medication regimes. Knowledge and vigilant observation for serious adverse effects such as the ones discussed in this article are essential if mental health nurses are to recognise, intervene and prevent fatalities that may be caused by a range of medications • Brian Keogh RPN, BNS, MSc is lecturer in mental health nursing. School of Nursing & Midwifery, Trinity College, Dublin Louise Doyle RPN, BNS, RNT, MSc is lecturer in mental health nursing, School of Nursing & Midwifery, Trinity College, Dublin