title: [Severe respiratory depression caused by incorrect connection of a PCA pump. : A case report.].
abstract: METHODS
  We report a case of severe respiratory depression during postoperative patient-controlled analgesia (PCA) in a 14-year-old boy. The medication cassette of a Pharmacia CADD-PCA 5200 was not properly connected, which led to a free-flow infusion of about 85 mg piritramide (strong mu-opioid agonist) within 15 min; the patient lost consciousness and developed apnea. He was successfully treated with artificial ventilation via ambu-bag and 0.2 mg naloxone i. v. The incident occurred approx. 2 h after the start of postoperative medication, when other infusions (suspended above the PCA device level) had been stopped, making the free-flow opioid infusion possible. As the PCA device was in a bedside pump enclosure, the disconnection was not immediately apparent.
  
  
  CONCLUSIONS
  Although PCA is considered a safe method, it can have potentially lethal complications: Technical problems or serious handling errors involve the risk of large volumes of analgesics being infused within a very short time. Therefore, we recommend apparative monitoring (e. g., pulse oximetry) as a necessary condition for the safe use of PCA.
authors.affiliation: Institut für Anaesthesiologie, Schmerzambulanz, Krankenhausstraße 12, D-91054, Erlangen.
authors.forename: D
authors.initials: D
authors.lastname: Boujong
authors.forename: N
authors.initials: N
authors.lastname: Grießinger
authors.forename: R
authors.initials: R
authors.lastname: Sittl