Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery
An 80-year-old, female patient, weighing 35 kg presented with biopsy proven squamous cell carcinoma of the left side of the mandible. She had no other comorbidities. She was taken up for wide excision with segmental mandibulectomy, modified radical neck dissection and reconstruction with pectoralis major myocutaneous flap. Pre-operatively, as per protocol, she received IV dexamethasone 8 mg on the day of surgery at 6 am. Patient was pre-medicated with fentanyl 50 μg. General anesthesia was induced with propofol and intubated with vecuronium. Anesthesia was maintained with N2O-O2-sevoflurane. Surgery lasted for 4 h. She was electively placed on endotracheal tube (ETT) with T-piece in the post-operative period in view of extensive surgery. In the PACU, another dose of 8 mg was administered. Fourteen hours after surgery, she became restless and she pulled out her ETT and Ryle's tube. She started bleeding from her suture site. She was wheeled into the operation theatre immediately for secondary suturing. After the surgery, she was placed on dexmedetomidine infusion for 12 h, initially at 0.3 μ/kg/h and then tapered to 0.1μ/kg/h (the infusion was stopped intermittently whenever the patient developed bradycardia or hypotension and whenever the patient remained calm). IV midazolam 1 mg and IM haloperidol 2.5 mg were continued 8 hourly for 2 days, after which the rest of post-operative period was uneventful. She was extubated 16 h after the surgery and then shifted back to the ward. She continued to be psychologically stable and was discharged on the post-operative day 8.