Lesson of the Week: Overdosage of opiate from patient controlled analgesia devices

When Keeri-Szanto described patient controlled analgesia in 1971 he observed that, because a large, potentially fatal amount of a narcotic drug is “hooked up” to the patient, fail safe methods of administering such drugs should be incorporated into the devices used. He suggested for example, that gravity feeding or syphoning should not be used.1 Since then five cases of overdosage from patient controlled analgesia devices that have been correctly set up have been reported.*RF 2-5* We report a case of overdosage in a young girl, which was apparently caused by a fault in the syringe in the patient controlled analgesia device that she was using.

Patient controlled analgesia devices must be correctly positioned and include safety features to prevent overdosage