Peri-operative dexamethasone therapy and post-operative psychosis in patients undergoing major oral and maxillofacial surgery
An 18-year-old, female patient, presented for surgery for mandibular prognathism. She was taken up for orthognathic surgery. Pre-operatively, as per protocol, she received intravenous (IV) dexamethasone 16 mg on the day of surgery at 6 am. Patient was pre-medicated with IV fentanyl 75 μg. General anesthesia was induced with propofol and intubated with vecuronium. Anesthesia was maintained with N2O-O2-sevoflurane. Surgery lasted for 4 h. After extubation, she was transferred to the post-operative care unit (PACU) awake and calm. On arriving at PACU, she was given another dose of dexamethasone, 8 mg. After 2 h, she became agitated, restless and aggressive. IV midazolam, propofol and IV fentanyl were administered for sedation, but the patient remained agitated and confused. Over the next 3 h, IV fentanyl 100 μg, propofol 40 mg, midazolam 4 mg was administered after which the patient was relatively calm. Then, she became restless and delirious. Psychiatry consultation was sought. She was diagnosed with an acute psychotic episode possibly induced by steroids. IV midazolam 2 mg and intramuscular (IM) haloperidol 4 mg were given. An IV dexmedetomidine infusion at 0.4 microgm/kg/min tapered to 0.2 microgm/kg/min, provided sedation for 6 h, after which it was stopped. As the patient continued to be calm over the next 12 h, she was transferred to the ward. She continued to be stable and was discharged on the post-operative day 5.