Shrey Shah, MD,
Pulmonary & Critical Care Fellow
Newark Beth Israel Medical Center
Newark, NJ
Disclosure information not submitted.
Fariborz Rezai, MD, FCCM
Director, Medical, Surgical and Neurosurgical ICU
Saint Barnabas Medical Center
Livingston, NJ
Disclosure information not submitted.
Ugo Okoroh, MD
Emergency Medicine Resident
Newark Beth Israel Medical Center, United States
Disclosure information not submitted.
Title: A Case of Hyperthermia of 107°F succesfully managed with intravascular heat exchange catheter
Case Report Body:
Introduction:
Neuroleptic malignant syndrome (NMS) is a life threatening neurologic emergency, which needs prompt recognition and treatment. We present to you a case of a 33-year-old pregnant female who was admitted to the ICU for NMS post C-section.
Case: 33-year-old pregnant female presented to the hospital in labor at full term. Due to failure of the fetus to descend, she was taken for an emergent C-section. She received 20mg of intravenous metoclopramide for nausea in the operating room. Labor analgesia was given via epidural bupivacaine and fentanyl. During the case, the patient mounted a fever which slowly increased to 102°F for which she received intravenous acetaminophen. Patient was transferred to a post-operative unit for monitoring. There, she slowly started to develop muscle rigidity and became obtunded. She was intubated and brought to the ICU. By the time the patient got to the ICU, her temperature had rapidly rose to a maximum of 107°F. The patient was diagnosed with NMS as a reaction to metoclopramide. She was given 5mg of IV midazolam, 2.5mg/kg of dantrolene. Gastric and bladder lavage was done with cold saline. She was started on a bolus of 1L cold normal saline. At this time, the patient's temperature came down to 105°F. A repeat dose of dantrolene 1mg/kg was given. An intravascular heat exchange catheter was placed and the patient's temperature was brought down to 98.4°F within 45 minutes. Next morning, the patient was taken off heat exchange catheter support and was able to maintain her temperature. Patient was extubated, and the catheter was removed.
Discussion: Managing hyperthermia in patients with NMS can be challenging. Non-invasive measures include external cooling with ice packs, forced air cooling, cold water blankets, refrigerated saline infusion [1]. Invasive options are cold saline lavage of body cavities, intravascular heat exchange catheters and ECMO [1]. There are 2 case reports of successful use of ECMO in malignant hyperthermia [2,3]. In our patient, we used an intravascular heat exchange catheter to achieve normothermia within 45 minutes. It is much less invasive than ECMO and requires less resources. Intravascular heat exchange catheters are a good alternative to ECMO in patients with persistent hyperthermia despite medical management.