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


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