Extracorporeal Cardiopulmonary Resuscitation in Cardiac Arrest Associated to Neuroleptic Malignant Syndrome: A Case Report

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening hypermetabolic reaction to dopamine-antagonist drugs that may progress to profound rhabdomyolysis, extreme hyperkalemia, and cardiac arrest (CA). Evidence guiding extracorporeal cardiopulmonary resuscitation (ECPR) for metabolic or toxic etiologies is scarce, and its use in NMS has not yet been described. We report the case of a 23 year old woman who presented with hyperthermia, severe muscular rigidity and laboratory evidence of NMS. In the emergency-department arrival she developed witnessed asystolic CA, unresponsive to conventional treatment. After a transient return of spontaneous circulation and a second refractory CA, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was initiated. Continuous hemodiafiltration facilitated rapid correction of extreme hyperkalemia, whereas dantrolene and active cooling normalized core temperature. Valid cardiac activity recovered after 36 hours, allowing ECMO weaning. However, devastating hypoxic-ischemic brain injury led to brain death, which was declared on day 5. Heart and liver procurement for transplantation were successfully performed. To our knowledge, implementation of ECPR in the context of NMS was not previously documented in the literature. Our case suggests that timely V-A ECMO might bridge extreme hyperkalemic arrest to cardiac recovery, offering both a chance of patient survival and, when neurological prognosis is dismal, an opportunity for organ donation.