• A Elannaz, A Chaumeron, E Viel, and J Ripart.
• Département anesthésie-douleur, hôpital Caremeau, CHU, 30029 Nîmes cedex 9, France. abdel.elannaz@tiscali.fr
• Ann Fr Anesth Reanim. 2004 Nov 1;23(11):1073-5.

AbstractWe report the case of a 67-year-female patient treated with a postoperative patient controlled analgesia using an Abbott Gemstar pump for after nephrectomy. In the postanaesthesia care unit, fifteen minutes after connecting with of the pump (which bag contained 100 mg of morphine) to the patient, respiratory arrest occurred. A morphine overdose was caused by uncontrolled delivery of the entire bag contents by free flowing due only to gravity. The patient was resuscitated immediately, and had uneventful recovery. This incident was the result of multiple misuse: one misconnection of the tubing between morphine bag and the patient thus shunting the antisiphon valve, and two an improper secured PCA cassette in an open position not detected by the pump. The tubing of these pumps and the software were subsequently modified by Abbott, which should reduce the risk of recurring incident. This accident points out that vigilance must remain rigorous in spite of widespread routine use of PCA.

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