Failure to wean due to steroid psychosis.

ince their introduction as therapeutic agents, corticosteroids have been associated with psychiatric symptoms ranging from mood disturbances to (florid) psychosis. By the time there have been reported psychotic reactions in patients receiving steroids or after sudden withdrawal of long time corticosteroids therapy. In this report a 40-year-old male patient known to have bronchial asthma since childhood, presented to the Accident and Emergency Department with marked shortness of breath. His medical history was otherwise unremarkable. Ventolin (ß2 agonist) and Atrovent (anticholinergic) was delivered via nebulizers and methylprednisolone was given at a dose of 60 mg intravenously (IV), every 6 hours. The patient's condition deteriorated over the next hours and he was subsequently electively ventilated via cuffed endotracheal tube and transferred to the medical intensive care unit (MICU). In the MICU, the patient was put on mechanical ventilator and was given the following drugs: methylprednisolone 60 mg, every 6 hours IV, nebulized Ventolin and Atrovent; midazolam and remifentanil IV. No muscle relaxants were used. On the following days, the patient became stable and he was prepared for weaning by tapering the dose of sedatives (midazolam and remifentanil). Remifentanil was stopped initially, while the patient remain calm, then midazolam was tapered gradually. As soon as the dose of midazolam decreased below the therapeutic level, the patient showed interrupted appearance of excitation and aggressiveness and fought with the ventilator, thus weaning was postponed. Investigations, including electrolytes, arterial blood gas, liver function test, chest x-ray and renal function tests were normal. Attempts to wean the patient continued but failed, as the patient became aggressive without sedatives, which makes the weaning process more difficult. Weaning failure were suspected due to steroid psychosis, methylprednisolon was withdrawn and haloperidol was administered, while the patient was kept on midazolam and bronchodilators. Psychotic symptoms, consisting of interrupted appearance of excitation and aggressiveness were gradually eliminated and completely disappeared at approximately 7 days after onset. On the following days, the patient behavior became reasonable, haloperidol and midazolam were stopped and weaning succeeded. S Brief Communication