Background and aims Epidural infusion of local anesthetics with opioids is widely used for pain control during the perioperative and peripartum periods. Selection of the opioid, appropriate dosing and follow-up by the acute pain service (APS) are critical in providing safe postoperative epidural analgesia. Epidural infusion of local anesthetics with opioids is widely used for pain control during the perioperative and peripartum periods. Selection of the opioid, appropriate dosing and follow-up by the acute pain service are critical in providing safe postoperative epidural analgesia.

Methods A 71-year-old male was scheduled for a parastomal hernia repair with midline laparotomy. The parastomal hernia was a complication from a previously performed colectomy for ulcerative colitis. Preoperatively, the patient received a lower thoracic epidural catheter. The epidural infusate (0,2% ropivacaine with 0,5 mcg/mL sufentanil) was prepared and double checked by holding area nurses. The fact that the right prescription medication label partially covered a morphine label went unnoticed. The intraoperative phase was characterised by stable parameters. Postoperatively, no pain was reported and the patient was transferred to the postsurgical ward.

Results The patient developed coma and respiratory depression 9 hours after discharge to the postsurgical ward, requiring ICU admission and naloxone administration. Analysis of the syringe content revealed the presence of morphine (1 mg/mL).

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Abstract ESRA19-0161 Figure 1

Conclusions This case report shows that the double check policy is insufficient in preventing medication error. Color coded prefilled syringes combined with the use of an epidural specific syringe connector to prevent cross-connections should become standard practice.