• D Boujong, N Grießinger, and R Sittl.
• Institut für Anaesthesiologie, Schmerzambulanz, Krankenhausstraße 12, D-91054, Erlangen.
• Schmerz. 1994 Dec 1;8(4):243-5.

Case ReportWe 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.DiscussionAlthough 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.

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