Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery
A 58-year-old, female patient, presented for surgery for wide local excision of squamous cell carcinoma of maxilla and closure with split skin graft. Pre-operatively, as per protocol, she received IV dexamethasone 16 mg on the day of surgery at 6 am. Patient was pre-medicated with IV fentanyl 100 μg. General anesthesia was induced with propofol and intubated with vecuronium. Anesthesia was maintained with N2O-O2-sevoflurane. Surgery lasted for 2 h. After extubation, she was awake and calm. On arriving at PACU, Another dose of 8 mg of dexamethasone was administered. After 6 h, she became restless and delirious. Psychiatry consultation was sought immediately. She too was diagnosed with an acute psychotic episode possibly induced by steroids. IV midazolam 2 mg and IM haloperidol 5 mg were administered. An IV dexmedetomedine infusion providing sedation was administered for 3 h at 0.4 μg/kg/h. She remained calm over the next 4 h after which she again became agitated. Midazolam 2 mg and haloperidol 2.5 mg were repeated. The dexmedetomidine infusion was restarted for next 6 h, initially at 0.4 μg/kg/h tapered to 0.2 μg/kg/h and then stopped. As the patient remained calm over the next 12 h, she was transferred to the ward. She continued to be psychologically stable and was discharged on the post-operative day 6.