Neuroleptic Malignant Syndrome During Mitral Valve Replacement Surgery: Considerations In Diagnosis And Management

Neuroleptic malignant syndrome (NMS) is an unusual idiosyncratic syndrome due to central dopaminergic antagonism or deficiency. It was rarely reported after or during cardiac surgery. Here we report a 64 years old female who was on dual NMScausing agents haloperidol for her schizophrenia and metoclopramide for her vomiting and developed NMS during her mitral valve replacement surgery. NMS and MH are two different entities but very difficult to differentiate during surgery. Other differential diagnoses include heat stroke, central nervous system infections, toxic encephalopathies, agitated delirium, status epilepticus, and more benign drug induced extrapyramidal symptoms Cardiac surgery involving cardiopulmonary bypass poses specific challenges because condituions-related to weaning off CPB such as rewarming process, metabolic acidosis, hemodynamic instabilities, dysrhythmias and hypercarnia can mimic the features of NMS. Maintaining a high index of suspicion if the patient had a history of psychiatric disorder and/or used antipsychotic medications preoperatively may facilitate early diagnosis and timely management with dantrolene and other systemic measures.