TRATAMENTUL PRIN TEC al unui caz de catatonie

TRATAMENTUL PRIN TEC al unui caz de catatonie maligna cu HTAPI Rusu Ionela-Mirabela Coord: Dr. Vornicu Brandusa

Introducere � PRIMUL caz de catatonie maligna= tratat prin 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

Introducere = HTAP > 25 mm. Hg ( 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 = morbimortalitate ↑ � HTAPI

Prezentare caz 23 ani – catatonie maligna ( Spitalul de Psihiatrie Tokyo ) � APP : -HTAPI-> la vs 8 ani ( PAP =50 mm. Hg ) -> T: beraprost + O₂-terapie la domiciliu -> HTAP progreseaza -> la vs 12 ani: T: epoprostenol ( PG I₂ ) pev ( eficienta temporara ) -> la vs 23 ani : IC cls III NYHA -DZ insulino-rezistent (la vs de 16 ani) -> T : insulinoterapie � Pacienta,

Prezentare caz � 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

Prezentare caz � Examenul v - fizic obiectiv la internare : Instabilitate autonoma si hemodinamica : Tahicardie HTA Glicemie 50 -400 mg/dl Hipertermie ( t⁰ =40⁰C ) � Tratament : -digitala orala 0. 125 mg/zi -spironolactona 25 mg/zi -warfarina 2 mg/zi -furosemid 40 mg/zi -epoprostenol -insulinoterapie

Examenul cardiovascular la internare: Cazul curent sistolica PAP (mm. Hg) diastolica medie CI (L/min/m 2) BNP (pg/ml) CR (%) EF (%) Saturatia oxigenului(%) 74 ↑ 27 ↑ 45 ↑ 3. 21 133. 4 ↑ 64 ↑ 53 ↘ 90 ↘ Valori normale 15– 28 5– 16 10– 22 2. 3– 4. 2 <20 50 55– 80 96– 99

Prezentare caz � 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 3 mg/zi p. o => dezvolta sindrom Capgras +agitatie psihomotorie + ideatie deliranta de persecutie - Levomepromazina 50 mg/zi + Aripiprazol 24 mg/zi =ineficiente

Prezentare caz Instabilitatea autonoma +hemodinamica -> pune in pericol viata pacientei => TEC ( Thymatron System IV ) � 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 �

Prezentare caz � 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 O₂ si NO )

Prezentare caz 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% (285 m. C ) � Durata medie a convulsiilor = 35. 9”EMG si 39. 3“ EEG � >14 sesiuni TEC: Scorul catatonie = 0 Statusul mintal = ameliorat �

Evolutia scorului catatoniei in timpul celor 14 sesiuni TEC

Prezentare caz �> 93 zile de la internare, pacienta a fost externata � Recomandari la externare: -Aripiprazol 30 mg/zi p. o -Acid valproic 600 mg/zi -Lorazepam 1 mg/zi -Zotepina 150 mg/zi -Digitala 0. 125 mg/zi -Spironolactona 25 mg/zi -Warfarina 2 mg/zi -Furosemid 40 mg/zi -Epoprostenol + insulinoterapie

DISCUTII PRIMA RAPORTARE a utilizarii TEC la un pacient HTAPI + 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 ) �

CONCLUZII � TERAPIA CU ELECTROSOCURI este o optiune acceptabila pentru tratamentul tulburarilor psihiatrice refractare la tratamentul medicamentos, in cazul pacientilor cu HTAP

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