目的:缺乏普遍接受的抗精神病药物恶性综合征(NMS)诊断标准阻碍了接受抗精神病药物治疗患者的研究和临床管理。这项研究的目的是制定反映临床知识专家广泛共识的NMS诊断标准,由国际多专业医师小组代表。
方法:11名精神科医生,2个神经科医生,2名麻醉师,2名急诊医学专家参加了正式的Delphi共识程序。
方法:由12个突出的核心参考书目组成,当前对NMS文献的评论是由一个目标确定的,全面的电子搜索策略。每个小组成员都获得了这些参考文献的副本,并要求在开始调查过程之前对其进行检查。
方法:在回顾了核心参考书目之后,小组成员被要求列出他们认为的任何临床体征或症状或诊断研究,根据他们的知识和临床经验,对NMS的诊断很有用。在随后的调查中,小组成员为这些项目分配了优先级点,并且未能获得最低优先级分数的项目从下一轮中被淘汰。有关单个小组成员响应的信息以小组中位数或平均值以及对每个调查项目进行排名或评分的成员人数的形式匿名反馈给小组。先验共识终点在操作上被定义为任何单个项目的平均优先级得分的10%或更小的变化。所有项目的平均绝对值变化为5%或更小,在连续回合之间。该调查于2009年1月至2009年9月进行。
结果:在第五轮中就以下标准达成共识:最近的多巴胺拮抗剂暴露,或多巴胺激动剂戒断;热疗;僵硬;精神状态改变;肌酸激酶升高;交感神经系统不稳定;心动过速加呼吸急促;以及其他原因的负面工作。小组还就这些标准的相对重要性以及以下定量标准的临界值达成了共识:热疗,>100.4°F或>38.0°C至少2次;肌酸激酶升高,至少是正常上限的4倍;血压升高,基线以上≥25%;血压波动,24小时内≥20mmHg(舒张压)或≥25mmHg(收缩压)变化;心动过速,高于基线≥25%;呼吸急促,基线以上≥50%。
结论:这些诊断标准极大地推动了该领域的发展,因为它们代表了国际多专业专家小组的共识,包括临界值,提供有关各个元素的相对重要性的指导,与以前发表的大多数标准相比,受特定理论偏见的影响较小。它们需要在临床环境中应用之前进行验证。
OBJECTIVE: The lack of generally accepted diagnostic criteria for neuroleptic malignant syndrome (NMS) impedes research and clinical management of patients receiving antipsychotic medications. The purpose of this study was to develop NMS diagnostic criteria reflecting a broad
consensus among clinical knowledge experts, represented by an international multispecialty physician panel.
METHODS: Eleven psychiatrists, 2 neurologists, 2 anesthesiologists, and 2 emergency medicine specialists participated in a formal Delphi
consensus procedure.
METHODS: A core bibliography consisting of 12 prominent, current reviews of the NMS literature was identified by an objective, comprehensive electronic search strategy. Each panel member was given a copy of these references and asked to examine them before commencing the survey process.
METHODS: After reviewing the core bibliography, panel members were asked to list any clinical signs or symptoms or diagnostic studies that they believed, on the basis of their knowledge and clinical experience, were useful in making a diagnosis of NMS. In subsequent survey rounds, panel members assigned priority points to these items, and items that failed to receive a minimum priority score were eliminated from the next round. Information about individual panel member responses was fed back to the group anonymously in the form of the group median or mean and the number of members who had ranked or scored each survey item. The a priori
consensus endpoint was defined operationally as a change of 10% or less in the mean priority score for any individual item, and an average absolute value change of 5% or less across all items, between consecutive rounds. The survey was conducted from January 2009 through September 2009.
RESULTS: Consensus was reached on the fifth round regarding the following criteria: recent dopamine antagonist exposure, or dopamine agonist withdrawal; hyperthermia; rigidity; mental status alteration; creatine kinase elevation; sympathetic nervous system lability; tachycardia plus tachypnea; and a negative work-up for other causes. The panel also reached a
consensus on the relative importance of these criteria and on the following critical values for quantitative criteria: hyperthermia, > 100.4°F or > 38.0°C on at least 2 occasions; creatine kinase elevation, at least 4 times the upper limit of normal; blood pressure elevation, ≥ 25% above baseline; blood pressure fluctuation, ≥ 20 mm Hg (diastolic) or ≥ 25 mm Hg (systolic) change within 24 hours; tachycardia, ≥ 25% above baseline; and tachypnea, ≥ 50% above baseline.
CONCLUSIONS: These diagnostic criteria significantly advance the field because they represent the consensus of an international multispecialty expert panel, include critical values, provide guidance regarding the relative importance of individual elements, and are less influenced by particular theoretical biases than most previously published criteria. They require validation before being applied in clinical settings.