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Objective Intrathecal drug delivery systems (intrathecal pumps) are used to treat patients with chronic refractory pain syndromes and spasticity. The objective of our case report was to demonstrate that intrathecal pump malfunction can lead to intrathecal overdosing of drugs. Case Report We present 2 cases of intrathecal pump malfunction leading to overinfusion. The first case concerns a patient with an intrathecal pump that was implanted almost 5 years before the reported incident. During a refill procedure, 12.5 mL was aspirated instead of the expected 21.8 mL. Analysis of the pump revealed that the pump was overinfusing. The second case concerns a patient with an intrathecal pump that was implanted more than 5 years before the reported incident. Ten hours after a regular refill of the pump, she was found in a comatose state, and when the intrathecal pump was emptied, only 16 mL was aspirated instead of the 19.6 mL expected. Analysis of the pump revealed that the inner tubing was not running smoothly over the roller arms, possibly causing spurts, which could have caused an overinfusion. Conclusions We present 2 cases of intrathecal pump malfunction, which most likely led to overinfusion of fentanyl intrathecally. To reduce the risk of this complication, particular attention should be paid to drug reservoir volume discrepancies and overdose symptoms reported by patients.

Context In some cases, physicians estimate that continuous sedation until death may have a life-shortening effect. The accuracy of these estimations can be questioned. Aim The aim of this study is to compare two approaches to estimate the potential life-shortening effect of continuous sedation until death. Methods In 2008, 370 Dutch physicians filled out a questionnaire and reported on their last patient who received continuous sedation until death. The potential life-shortening effect of continuous sedation was estimated through a direct approach (question: Did continuous sedation, according to your estimation, hasten the patient’s death? If yes: by how much time?) and an indirect approach (estimated life expectancy minus duration of sedation). The intrarater agreement between both approaches was determined with a weighted κ. Results According to the direct approach, sedation might have had a life-shortening effect in 51% of the cases and according to the indirect approach in 84%. The intrarater agreement between both approaches was fair (weighted κ=0.38). In 10% of all cases, the direct approach yielded higher estimates of the extent to which life had been shortened; in 58% of the cases, the indirect approach yielded higher estimates. Conclusions The results show a discrepancy between different approaches to estimate the potential life-shortening effect of continuous sedation until death.

Introduction and aims Palliative sedation is a palliative care intervention for relieving severe suffering in the last phase of life. This study aims to distinguish characteristics of adequate sedation outcome compared to less favourable outcome based on physicians9 reports. Methods In 2008, a structured questionnaire was sent to a random sample of 1580 physicians working in general practice, nursing homes and hospitals regarding their last patient receiving continuous sedation until death. Adequate outcome was defined as cases where adequate relief of symptoms, good to very good quality of death and no adverse reactions were reported by the physician. Results A total of 606 physicians (38%) filled out the questionnaire, of whom 370 (61%) reported about their last case of continuous deep sedation. Cases characterised as adequate outcome (n=110) significantly more often had nausea (16% vs 7%), but less often delirium (7% vs 15%) as decisive indication for palliative sedation. Significantly more often, cases defined as adequate were sedated with the (partial) intention of hastening death (19% vs 13%), exhibited a shorter median duration of sedation (32 (IQR 16–48) versus 48 (IQR 24–73) h), had a shorter median duration to reach the required sedation depth (2 (IQR 1–4) versus 4 (IQR 2–12), were more often sedated deeper (94% vs 84%) and received a stable administration of benzodiazepines and opioids (52% vs 26%). Conclusion Differences between perceived adequate and less adequate sedation outcome may be related to intention and mode of administration of palliative sedation.