Accidental intrathecal sufentanil overdose during combined spinal-epidural analgesia for labor.
A laboring woman was accidentally given 45 microg of sufentanil intrathecally in the course of combined spinal-epidural analgesia. She experienced intense pruritus and transient swallowing difficulty without respiratory depression, but still had incomplete pain relief, with delivery and episiotomy repair requiring additional analgesia. This case highlights the importance of adding local anesthetic to intrathecal opioids to facilitate effective analgesia during the second stage of labor. The contributory systems issues and multiple factors that allowed this error to occur are examined.
Coleman
L
L
Department of Anesthesia, Stanford University School of Medicine, Stanford, California 94305, USA.
Carvalho
B
B
Lipman
S
S
Schmiesing
C
C
Riley
E
E
D000328:Adult; D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects* / Q000037:antagonists & inhibitors; D000767:Anesthesia, Epidural; D000773:Anesthesia, Obstetrical; D000775:Anesthesia, Spinal; D062787:Drug Overdose; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D008508:Medication Errors; D009270:Naloxone / Q000494:pharmacology; D009292:Narcotic Antagonists / Q000494:pharmacology; D011247:Pregnancy; D011537:Pruritus / Q000139:chemically induced / Q000188:drug therapy; D017409:Sufentanil / Q000008:administration & dosage / Q000009:adverse effects* / Q000037:antagonists & inhibitors; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D009292:Narcotic Antagonists; D009270:Naloxone; D017409:Sufentanil