A Safer Approach to an Anesthetic Conundrum: Electroconvulsive Therapy for a Case of Acute Psychosis with Neuroleptic Malignant Syndrome

Abstract We report a case involving a 20-year-old male with no known comorbidities, being treated as a case of acute psychosis. Presented with fever, inability to speak, limb stiffness, profuse sweating, tremors, and rigidity of bilateral upper and lower limbs following administration of antipsychotics. A provisional diagnosis of neuroleptic malignant syndrome (NMS) was made based on Levenson’s criteria. His antipsychotics were discontinued, and he was transferred to the intensive care unit for critical care support. With lorazepam, his NMS symptoms improved. However, in view of residual psychotic symptoms, the decision was made to commence electroconvulsive therapy (ECT). A combination of rocuronium sugammadex was used successfully in all his ECT procedures and found to be an excellent alternative to avoid succinylcholine, in view of the shared pathophysiology of NMS with malignant hyperthermia, in this patient.