Introduction: Acute pain service (APS) ensures provision of effective and safe postoperative pain relief. The following cases describe a potentially fatal error in managing patients who receive epidural analgesia postoperatively.
Case report summary: Three patients who received 6-8 ml/hr epidural infusion of 0.1% levobupivacaine with 2 μg/ml fentanyl (cocktail) developed poor arousal, hypopnoea and hypercarbia 16-18 hrs postoperatively. They required mechanical ventilation in the Intensive Care Unit (ICU) and exclusion of neurological and cardiac causes. Haemodynamically, they remained stable at the time of referral and throughout their ICU stay. All 3 patients were extubated within 24 hours uneventfully.
Discussion: Following an inquiry, it was found that all three epidural cocktails came from the same batch of preparation. Analysis of the contents revealed high concentrations of morphine without traces of levobupivacaine. The epidural cocktail infusion and patient-controlled analgesia (PCA) morphine syringes were prepared in identical 50-ml syringes at the same setting but were labeled separately by different personnel.
Conclusion: A defined APS protocol should ensure patients' safety. If the protocol is strictly adhered to and with regular audits, preventable errors can be avoided. The acute pain service provider must be alert and responsive to warning signs of any protocol errors.
Keywords: Morphine epidural; human error; medication error; postoperative analgesia; respiratory depression.