glucocorticosteroids have been used in an attempt to minimize or prevent post - operative edema after oral and maxillofacial surgery .
dexamethasone seems to be the most suitable because it has the highest anti - inflammatory activity , no mineralocorticoid activity and a longest available half - life of 36 - 54 h. psychosis is a generic psychiatric term for a mental state often described as involving a  loss of contact with reality .  people experiencing psychosis may report hallucinations or delusional beliefs and they may exhibit personality changes and disorganized thinking .
we report three maxillofacial cases who experienced post - operative psychosis after peri - operative dexamethasone therapy , as a result of which , the patients had a prolonged stay in the surgical intensive care unit .
- operatively , as per protocol , she received intravenous ( iv ) dexamethasone 16 mg on the day of surgery at 6 am .
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 .
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 g , propofol 40
iv midazolam 2 mg and intramuscular ( i m ) 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 .
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 .
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 .
an iv dexmedetomedine infusion providing sedation was administered for 3 h at 0.4 g / kg / h .
the dexmedetomidine infusion was restarted for next 6 h , initially at 0.4 g / kg / h tapered to 0.2 g / 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 .
an 80-year - old , female patient , weighing 35 kg presented with biopsy proven squamous cell carcinoma of the left side of the mandible .
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 .
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 .
after the surgery , she was placed on dexmedetomidine infusion for 12 h , initially at 0.3 /kg / h and then tapered to 0.1/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 i m 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 .
- operatively , as per protocol , she received intravenous ( iv ) dexamethasone 16 mg on the day of surgery at 6 am .
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 .
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 g , propofol 40
iv midazolam 2 mg and intramuscular ( i m ) 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 .
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 .
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 .
an iv dexmedetomedine infusion providing sedation was administered for 3 h at 0.4 g / kg / h .
the dexmedetomidine infusion was restarted for next 6 h , initially at 0.4 g / kg / h tapered to 0.2 g / 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 .
an 80-year - old , female patient , weighing 35 kg presented with biopsy proven squamous cell carcinoma of the left side of the mandible .
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 .
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 .
after the surgery , she was placed on dexmedetomidine infusion for 12 h , initially at 0.3 /kg / h and then tapered to 0.1/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 i m 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 .
glucocorticosteroids are used extensively for minimizing and preventing post - operative oedema after oral and maxillofacial surgery .
dexamethasone seems to be the most suitable because it has the highest anti - inflammatory activity , no mineralocorticoid activity and a longest available half - life of 36 to 54 h. dexamethasone has also been in use in the peri - operative period for post - operative nausea and vomiting pain management and in neurosurgery . even though , efficacious for preventing and minimizing edema in oral and maxillofacial surgeries ,
there have been reports attributing post - operative psychosis to peri - operative dexamethasone [ table 1 ] .
in fact in one of the reports a single dose has been implicated for the development of post - operative psychosis .
while the incidence of post - operative delirium is 36.8% , acute steroid related psychiatric disorder frequency is 5% . in view of such a high incidence
, it may be imperative that , with every case where peri - operative dexamethasone is administered , a post - operative psychotic reaction should be anticipated . in patients who are being post - operatively ventilated
, it may be necessary to use restraints to prevent self - extubation and a pre - operative consent for the same would be required .
the episodes of psychosis can prolong the hospital stay or may result in readmission and increase the total cost for the patient . early recognition and
once there is a psychotic event , the stay of the patient is prolonged in the intensive care units thereby increasing the costs
. the exact dose of dexamethasone that can cause a psychotic reaction is unknown . since it has been reported that a single dose can cause post - operative psychosis [ table 1 ] all patients receiving dexamethasone have to be monitored carefully post - operatively
special care has to be taken in patients who have a previous history of psychiatric disorders .
awareness and the ability to diagnose post - operative psychosis following use of peri - operative dexamethasone are crucial to provide better care and effective treatment .
 a broad array of behavioral symptoms , including psychosis , can transpire post - operatively following a variety of surgeries . 
 it is difficult to diagnose the exact cause of post - operative psychosis . 
 we report three cases , which developed psychosis post - operatively after undergoing major oral and maxillofacial surgeries . 
 all the three patients were administered dexamethasone peri - operatively . 
 dexamethasone is used to prevent or reduce post - operative edema . 
 the exact dose of dexamethasone , which can cause psychosis , is unknown . 
 it is important to raise awareness about this potential complication so that measures for management can be put in place in anticipation of such an event . 
Introduction
Case Reports
Case 1
Case 2
Case 3
Discussion
Conclusion