Accidental epidural administration of a high dose of sufentanil

Epidural sufentanil infusions are routinely used for post-operative analgesia after high-abdominal and thoracic surgery in our hospital. The erroneous administration of a bolus of 250 micrograms of sufentanil epidurally was followed by a 24 hour episode of deep analgesia and respiratory depression. The recovery from respiratory depression over a 27 hour period is described.