• Lindsay Warner, Anna Branstad, Lindsay Hunter Guevara, Laura Matzke Bitterman, Matthew Pingree, Wayne Nicholson, and Jason Eldrige.
• Department of Anesthesiology, Mayo Clinic, 200 1st SW, Rochester, MN, 55902, USA. warner.lindsay@mayo.edu.
• J Med Case Rep. 2020 Jan 3; 14 (1): 1.

BackgroundSufentanil is a potent opioid uncommonly used to manage pain and is rarely administered via an intrathecal pain pump system.Case PresentationThis case illustrates the use of intrathecal sufentanil in a 50-year-old Caucasian man for the management of chronic pain; however, the intrathecal drug delivery system experienced a malfunction which led to 1/100th output of the correct dosage. Interesting aspects of this case report include the uncommon choice of sufentanil use for an intrathecal drug delivery system, as well as the unusual pharmacokinetics of this drug. Specifically, this patient did not experience the major withdrawal that would be expected given significant under dosing of opioid, and this may be explained by the lipophilicity and context-sensitive half-times of sufentanil.ConclusionsBecause of the absence of a clinically significant withdrawal in this case report, clinicians must be aware of relevant pharmacokinetic properties and unusual intrathecal drug delivery system technologies that influence a patient's response when device malfunction occurs.

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