A 51-year-old woman (75,600 Kg - 1,57 M) ASA II (centrolobular breast cancer, tamoxifen treatment) posted for right postmastectomy free flap . Induction with fentanyl (2mcg / Kg), propofol (2.5 mg / kg), rocuronium (0.6 mg / Kg), maintenance remifentanil (0.14 µg / Kg / ml) sevoflurane 2% and BRC 0.06 mg / kg / h. Right jugular central line guided by ultrasound .  Thirty minutes after beginning  200 mgs of dexamethasone phosphate (Fortecortin® ) were accidentally administered , being  notified 5 minutes after. Arterial and venous hourly gasometry  only showed  mild hypocalcemia. Crystalloids and furosemide (20mg) were administered. Total surgical time: 6 hours. 

90 minutes postsurgery the patient was stuporous (responding only to painful stimuli), Glasgow  4 points,  without airway reflexes. She was extubated in UCPA two hours later, at that moment responding to both verbal and tactile stimuli but was very drowsy and bradypsychic. Brain CT scan was normal. For the next 48 hours she remained in UCPA, sleep,  normal cortisol and ACTH levels. Persistent nystagmus was observed for 3 days. Seven days after surgery, she presented loss of consciousness and rigidity when removing  the central line; myoclonus and alternating hemiplegia appeared but CT and  EEG showed any patological findings. MRI showed diffuse alteration of the cortical signal. A diagnosis of reversible posterior encephalopathy was considered. 5 days after this episode mioclonus and alternating hemiplegias  persisted  without any injuries to justify them  so the patient was discharged  and sent for   psychiatric evaluation with a final diagnosis of conversive disorder.Meta searchers  (Tripdatabase, Epistemonikos, UpToDate) confirm
 that there are few or no reported cases of accidental acute overdose
 of dexamethasone in patients undergoing long-time surgeries.
Dexamethasone is a glucocorticoid  with great anti-inflammatory properties, equivalent to 25 or 30 times that obtained with cortisone. It is mainly based on the inhibition of fibrin deposits, capillary dilation and inhibition of the migration of leukocytes to the inflamed area.
 In our case, the patient presented hydroelectrolytic alterations (hypocalcemia), as well as disorders in the CNS reflected in the delay in awakening and subsequent development of clinical picture compatible with a conversion disorder  vs a reversibleposterior encephalopathy. 


07 / Overdose By Sodium Phosphate Dexamethasone