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SummaryA patient is described in whom respiratory arrest occurred 55 min after thoracic extradural administration of I I ml of a solution containing 25 mg bupivacaine and 50 pg sufentanil. Key wordsAnaesthetic techniques, regional; extradural. Analgesics; sufentanil. Complications; respiratory arrest.Extradural opioids may cause respiratory depression, and morphine has been associated with late respiratory depression several hours after epidural injection. Its lipid solubility is low and rostral spread, thought to be the mechanism of action, may be considerable [I]. Sufentanil has a greater lipid solubility than morphine and may be expected to clear more rapidly from the cerebrospinal fluid, which allows for less rostral spread. In addition, sufentanil has not been associated with late respiratory depression. A patient is presented in whom respiratory arrest occurred 55 min after thoracic extradural administration of a solution containing bupivacaine 25 mg and sufentanil 50 pg. Case historyA previously healthy 25-year-old Asian male was admitted with a 2 day history of slowly progessive dyspnoea and pain in the right side of the chest. On examination, the patient was tachypnoeic and pale. His rectal temperature was 37.8"C, blood pressure 130/90 mmHg and the pulse was regular at 80 beat.min-'. On the right side, percussion of the thorax was hyper-resonant and respiratory sounds were absent on auscultation. No further abnormalities were found.Serum electrolytes, arterial blood gas analysis and red and white blood cell counts were all within normal limits. A chest X ray showed a complete collapse of the right lung and left-sided displacement of the heart and mediastinum.A diagnosis of spontaneous pneumothorax was made and an emergency right-sided chest drain with underwater seal was inserted.The patient was scheduled for thoracoscopy and pleurodesk with iodine-containing talc the next day. Before thoracoscopy, the patient was given midazolam 2.5 mg intravenously and an extradural catheter was inserted through the fourth thoracic vertebral interspace while the patient was sedated but awake. In incremental doses, a total of 11 ml of a solution containing bupivacaine 25 mg without adrenaline and sufentanil 50 pg was administered epidurally. (The solution was prepared by adding I ml containing sufentanil50 pg to bupivacaine 10 mlO.25%.) A bilateral sensory block ensued, extending from the second thoracic to the first lumbar dermatome, as determined by loss of sensation to temperature. No adverse signs were observed and 20 min after the start of extradural analgesia, thoracoscopy and pleurodesis were performed and chest drainage inserted with the patient awake and experiencing no pain. Five minutes after return to the recovery room and 55 min after institution of extradural analgesia, the patient suddenly became drowsy and his oxygen saturation, as measured by pulse oximetry, decreased. He failed to respond to verbal commands and respiration ceased completely. Manual ventilation by face mask with 100% oxygen was perform...

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