MORPHINE OVERDOSE IN A PATIENT USING PATIENT CONTROLLED ANALGESIA (PCA) - A CASE REPORT

Abstract

Background:

Good post-operative pain control is crucial to the success of the surgery and the wellbeing of the patient. Pain relief after surgery is the most important concern amongst patients. The term, PCA, refers to on-demand, periodic intravenous administration of opioids, which can be operated by the patient to administer self- medication. The use of PCA has improved control of pain in the immediate period after surgery. The use of these advanced machines with a high degree of complexity has led to the addition of new sources of errors including programming errors.

Case Description:

A twenty-one years old male patient with a confirmed diagnosis of a soft tissue tumor “angiomatoid fibrous histiocytoma”, was enlisted for excision of the tumor tissue with groin nodes clearance along with pedicled posterior tibial artery propeller flap. Initially, epidural was used for postoperative analgesia. However, due to continuous motor blockade, the decision was made to discontinue the epidural and use PCA morphine for controlling postoperative pain. Due to an error in setting up of the electronic device, 45 mg of morphine was administered to the patient instead of 1 mg bolus. After an interval of five minutes post-drug administration, the patient complained of nausea, headache, and vertigo.

Practical Implications:

On duty nurse immediately alerted the anesthesia team about the morphine overdose. The patient was shifted to the surgical extended care unit for monitoring of the cardiac and respiratory function. The patient’s haemodynamic parameters remained within the normal range and no airway intervention was required.

Recommendations:

Based on this incident, regular training of the anesthesia trainees should be carried out and software of the PCA devices should be adjusted to minimize errors when complex parameters are entered