Death Related to Midazolam Overdose During Endoscopic Retrograde Cholangiopancreatography

Abstract

We report a midazolam-related death that occurred during endoscopic retrograde cholangiopancreatography (ERCP). The acute intoxication due to midazolam overdose was confirmed by high-pressure liquid chromatography (HPLC) analysis of the blood samples taken from the patient in the intensive care unit (2.8 microg/ml) and postmortem (2.4 microg/ml). The case strongly emphasizes the necessity of the precautions that should be taken when midazolam is intravenously administered.

Determination of midazolam in human plasma by solid‐phase microextraction and gas chromatography/mass spectrometry

“…37 However, 4‐hydroxymidazolam is not detectable in human plasma following subtherapeutic midazolam doses,12 or detectable at sub‐ng/ml levels following therapeutic doses;25 in addition, the more important active metabolite 1‐hydroxymidazolam is always found in much lower plasma concentrations than midazolam 12,. 17 Thus, the described method may be usefully applied in cases of acute midazolam intoxication,38 within diagnostic procedures for brain death ascertainments,39–41 assays following fatal overdoses,6,, 24,, 42,, 43 or in cases of driving under the influence of drugs 44,. 45 In most of these applications, a negative or positive midazolam assay may help to screen samples with respect to further and possibly more complex chromatographic analyses.…”

Midazolam in conjunction with local anaesthesia is superior to Entonox in providing pain relief during bone marrow aspirate and trephine biopsy

“…We found that midazolam was superior in alleviating pain or pain recollection during bone marrow biopsy, but its use is not without hazard. Deaths have been reported in other procedures after midazolam treatment, even in patients undergoing conscious sedation 19. In this study clinically important hypoxaemia was reversed by flumazenil in three patients (13%); the use of midazolam sedation requires the full precautions described by the Royal College of Anaesthetists to be taken.…”

Analysis of 153 deaths after upper gastrointestinal endoscopy: room for improvement?

“…Sedation-related adverse events occur in 6.5/1,000 endoscopic procedures [6] and may result from an overdose of the sedative agent [2,15]. Problems with sedation and aspiration contributed to the death of three patients in this series.…”

“…Perforation at upper GI endoscopy and pancreatitis subsequent to ERCP are well-recognized complications, particularly for therapeutic procedures [7,10,16,22]. However, delays in the endoscopy or in implementing therapy, aspiration pneumonia [16,20], oversedation [15,16], inexperience of the surgeon [16], and even performance of the wrong procedure remain rare, although potentially avoidable, adverse events.…”