Catatonia Maligna and Its Complex Management in a Schizophrenic Patient
Learn about the urgent and life-threatening condition of catatonia maligna in a 23-year-old schizophrenia patient. Explore the challenges and treatment strategies for managing this complex case, which involves a combination of psychiatric and medical care, including addressing complications like severe pulmonary arterial hypertension (HTAP). Discover the critical role of systemic care and quick intervention in ensuring patient safety and well-being.
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Rusu Ionela-Mirabela Coord:Dr.Vornicu Brandusa
PRIMUL TEC, la o pacienta cu schizofrenie si HTAPI (6 mai 2016,BMC Psychiatry, Mizue Hobo ) Metode de reducere a riscului complicatiilor fizice CATATONIA MALIGNA = urgenta psihiatrica si medicala ce pune in pericol viata => necesita ingrijire sistemica si remediu rapid PRIMUL caz de catatonie maligna= tratat prin
HTAPI = HTAP > 25 mmHg ( Simpozion Mondial HTAP primitive 1998 ) HTAPI netratata = boala cardiovasculara progresiva si fatala HTAPI + afectiune psihiatrica/alte complicatii = ATENTIE DEOSEBITA in cazul administrarii terapiei medicamentoase (modificari hemodinamice ) HTAPI + anestezie/chirurgie = morbi- mortalitate
Pacienta, 23 ani catatonie maligna ( Spitalul de Psihiatrie Tokyo ) APP -HTAPI-> la vs 8 ani ( PAP =50 mmHg ) -> T:beraprost + O -terapie la domiciliu -> HTAP progreseaza -> la vs 12 ani:T: epoprostenol ( PG I ) pev ( eficienta temporara ) -> la vs 23 ani : IC cls III NYHA -DZ insulino-rezistent (la vs de 16 ani) -> T : insulinoterapie APP :
Istoricul medical semnificativ = afectiunile psihiatrice Debut : la vs 20 ani-internare pt tentativa suicid pe fondul unei tulburari depresive + agitatie psihomotorie + fenomene psihotice Diagnostic internare: Depresie cu elemente psihotice Tratament : antidepresive + antipsihotice Reevaluare diagnostic : Schizofrenie La vs 23 ani : - non-complianta la tratamentul psihiatric - agitatie psihomotorie + mutism +catalepsie - reinternare
Examenul fizic obiectiv la internare Instabilitate autonoma si hemodinamica - Tahicardie - HTA - Glicemie 50-400 mg/dl - Hipertermie ( t =40 C ) Tratament : -digitala orala 0.125mg/zi -spironolactona 25mg/zi -warfarina 2mg/zi -furosemid 40mg/zi -epoprostenol -insulinoterapie Examenul fizic obiectiv la internare : Instabilitate autonoma si hemodinamica : Tratament :
Valori normale 15 28 5 16 10 22 2.3 4.2 <20 50 55 80 Cazul curent sistolica 74 27 45 3.21 133.4 64 53 PAP (mmHg) diastolica medie CI (L/min/m2) BNP (pg/ml) CR (%) EF (%) Saturatia oxigenului(%) 96 99 90
IRM cerebral+ EEG + LCR = aspect normal Delir + mutism+ catalepsie + hiperpirexie + instabilitate vegetativa=>CATATONIE MALIGNA Scorul de evaluare al catatoniei Bush-Francis =23 ( la internare ) Tratament - Lorazepam 3mg/zi p.o => dezvolta sindrom Capgras +agitatie psihomotorie + ideatie deliranta de persecutie - Levomepromazina 50mg/zi + Aripiprazol 24mg/zi =ineficiente CATATONIE MALIGNA 23 Tratament:
Instabilitatea autonoma +hemodinamica -> pune in pericol viata pacientei => TEC Principala complicatie posibila = criza HTAP Masuri de siguranta ( in timpul sesiunilor tec ): -monitorizarea statusului functiei cardio-pulmonare -intubatie oro-traheala -NO pentru o posibila criza ( dilatarea a.pn ) -epoprostenol pev cont. in tp fiecarei proceduri tec (previne HTAP ) -propofol ( =anestezic ) injectomat la o conc 3-4 mcg/ml -remifentanil : opioid cu durata scurta de actiune,puternic anestezic, dz: 0.5-1 mg/h, stabilizator al tensiuni arteriale - rocuroniu 0,8 mg/kg : relaxant muscular TEC ( Thymatron System IV ) criza HTAP
Electrozii = bilateral la toate sesiunile TEC Prima sesiune TEC : - doza de stimulare = 25% - convulsii timp de 59 pe EMG si 69 pe EEG In timpul intubatiei/postconvulsie =tahicardie, dar TA= valori normale => Nu! Constrictie arteriala => Nu a fost necesar NO Pacienta acuza odinofagie importanta + necesitatea a > 10 sedinte de TEC => inlocuirea intubatiei cu masca laringiana ( pt admin O si NO )
Tulburarile hemodinamice si ale SNV (tahicardie, HTA, fluctuatii glicemice, hipertermia ) = atenuate treptat > 9 sesiuni TEC : parametrii= V.N. Total : 14 sesiuni Doza de stimulare medie = 56.6% (285mC ) Durata medie a convulsiilor = 35.9 EMG si 39.3 EEG >14 sesiuni TEC:Scorul catatonie = 0 Statusul mintal = ameliorat
> 93 zile de la internare, pacienta a fost externata Recomandari la externare: -Aripiprazol 30mg/zi p.o -Acid valproic 600mg/zi -Lorazepam 1 mg/zi -Zotepina 150mg/zi -Digitala 0.125mg/zi -Spironolactona 25 mg/zi -Warfarina 2 mg/zi -Furosemid 40 mg/zi -Epoprostenol + insulinoterapie Recomandari la externare:
PRIMA RAPORTARE catatonie maligna TEC = prima linie in catatonia maligna ( desi HTAP + anestezia => mortalitate ) Criza de HTAP = cea mai importanta posibila complicatie Criza de HTAP= consecinta ingustarii rapide a arterelor pulmonare ( indusa de hipoxie + stimularea simpatica ) => IC dreapta=>hipoxie severa Acest risc prin: -IOT /masca laringiana ( oxigenare suficienta + preventia hipercapniei ) -remifentanil = anestezic puternic cu durata scurta de actiune ( atenuarea HTA indusa de IOT ) - NO ( necesar in caz de criza HTAP ) PRIMA RAPORTARE a utilizarii TEC la un pacient HTAPI +
TERAPIA CU ELECTROSOCURI este o optiune acceptabila pentru tratamentul tulburarilor psihiatrice refractare la tratamentul medicamentos, in cazul pacientilor cu HTAP TERAPIA CU ELECTROSOCURI
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