Inadvertent epidural administration of remifentanil (Ultiva®) during labour analgesia

Inadvertent epidural administration of remifentanil (Ultiva®) during labour analgesia

Dany Khodra

aReplacement Anesthesiologist in Belgium

International-Journal-of-Case-Reports-2d code

The use of remifentanil patient-controlled analgesia for labour analgesia remains controversial. The high potency of the drug, the fear of serious adverse drug reactions and drug administration errors are all legitimate concerns. We report the case of a woman in labour who inadvertently received a remifentanil solution via epidural route. In addition to the risk of respiratory depression, the epidural administration of remifentanil contains glycine in its solution and is therefore contraindicated due to potential neurological injury. The patient received a total of 2 mg of remifentanil and 15 mg of glycine in her epidural over a long period before the error was identified. Interestingly the patient was mostly comfortable during labour and fortunately no maternal or neonatal adverse events occurred.

Keywords: remifentanil; glycine; epidural; obstetrical analgesia; medical errors; human factor

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How to cite this article:

Dany Khodr. Inadvertent epidural administration of remifentanil (Ultiva®) during labour analgesia . International Journal of Case Reports, 2019 4:75. DOI: 10.28933/ijcr-2019-01-2506


1. Sng, B. L., & Sia, A. T. H. (2017). Maintenance of epidural labour analgesia: The old, the new and the future. Best Practice & Research Clinical Anaesthesiology, 31(1), 15–22.
2. Lee, M., Zhu, F., Moodie, J., Zhang, Z., Cheng, D., & Martin, J. (2017). Remifentanil as an alternative to epidural analgesia for vaginal delivery: A meta-analysis of randomized trials. Journal of Clinical Anesthesia, 39, 57–63.
3. Stourac, P., Kosinova, M., Harazim, H., Huser, M., Janku, P., Littnerova, S., & Jarkovsky, J. (2016). The analgesic efficacy of remifentanil for labour. Systematic review of the recent literature. Biomedical Papers, 160(1), 30–38.
4. Lancet 2018; 392: 662–72 Published Online, August 13, 2018
5. Kranke P, Girard T, Lavand’homme P, et al. Must we press on until a young mother dies? Remifentanil patient controlled analgesia in labour may not be suited as a “poor man’s epidural”. BMC Pregnancy Childbirth 2013; 13: 139.
6. Product information: Ultiva, remifentanil hydrochloride. Glaxo Wellcome, Kalamazoo, MI, USA, 1999.
7. Buerkle H, Yaksh TL. Continuous intrathecal administration of shortlasting mu opioids remifentanil and alfentanil in the rat. Anesthesiology. 1996; 84: 926-935.
8. Xu X, She S, Yao S, Mok M, Zuo Z. Respiratory depression and difficult ventilation after inadvertent epidural administration of remifentanil. Anesth Analg. 2007; 104: 1004.
9. Nishimoto K, Sakamoto S, Mikami M, Hirota K, Shingu K. Accidental administration of the remifentanil formulation Ultiva™ into the epidural space and the complete time course of its consequences: a case report. Clin Rep. 2016; 2:19.
10. López-Soriano F, Rivas F, Lajarín B. Cartas al director: Administración accidental de remifentanilo epidural y ropivacaina intravenosa. Farm Hosp. 2007; 31: 128-136.
11. Minto CF, Schnider TW, Egan TD, et al. Influence of age and gender on the pharmacokinetics and pharmacodynamics of remifentanil. I. Model development. Anesthesiology. 1997; 86:10-23.
12. Minto CF, Schnider TW, Shafer SL. Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anesthesiology. 1997; 86: 24-33.
13. Talmage D, Egan TD; Minto CF, et al. Remifentanil versus alfentanil: comparative pharmacokinetics and pharmacodynamics in healthy adult male volunteers. Anesthesiology. 1996; 84; 821-833.
14. Fierheller EE, Caulkett NA, Bailey JV. A romifidine and morphine combination for epidural analgesia of the flank in cattle. Can Vet J. 2004; 45: 917–923.
15. Reason J. Human error: models and management. BMJ. 2000, 320: 768-770
16. Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn, LT, Corrigan, JM, Donaldson, MS (eds). To err is human: building a safer health system. Washington, DC; National Academy Press. 2000
17. Neurax® NR-fit system. Available at: .

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