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To the Editor: I wish to report a ease of acute respiratory arrest following apparently satisfactory recovery from general anaesthesia supplemented with sufentanil. The patient was a 61-year-old, 68 kg female presenting for hemicolectomy. She was premedicated with oxazepare 30 mg PO and morphine 8 mg IM 90 minutes before surgery. Thiopentone 100mg, sufentanil 150 I-~g and succinylcholine 120rag were administered IV and the trachea was intubated. The patient was ventilated with nitrous oxide 60 per cent and oxygen 40 per cent ~nd pancuronium 4 mg was administered IV. Thirty minutes later, following the surgic',d incision, sufentanil 25 ixg was administered in response to increases in pulse and blood pressure. Isoflurane 0.25-0.5 per cent was added in response to similar responses to surgical stimulation. At the end of surgery pyridostigmine 20 mg and atropine 1.2 mg wcrc administered IV. One hundred and sixty-five minutes after anaesthetic induction the patient was awake and extubated herself in the operating room. When the patient was transferred to the recovery room she was breathing well, oriented and talking to the anaesthetist. In the recovery room, ten minutes following extubation, the patient's vital signs were normal, including respiratory rate of 18. rain -1. She was conscious, oriented and talking with the nurses. Fifteen minutes following extubation the patient was noted to be apnoeic, cyanotic and unresponsive to commands or deep pain. The patient responded immediately to the administration of naloxone 0.2 mg IV and within 60 seconds she was awake, breathing spontaneously and responding appro priately. Her subsequent course was uneventful. Respiratory depression after anaesthesia with a narcotic is well recognized. The rapidity with which this patient became apnoeic and the depth of narcosis was unusual. Chang et al.l reported a similar case of post-anaesthetic respiratory depression with associated chest wall rigidity following sufentanil, while Goldberg et al. 2 described a more gradual onset of respiratory depression, again associated with chest wall rigidity. Both reports concluded that the use of moderately high doses of sufentanil (2-5 I~g.kg -~) as a supplement to anaesthesia could be associated with significant respiratory depression in the early postoperative period. In this dose range, the duration of respiratory depression produced by sufentanil is said to be comparable to that seen with fentanyl. In our department, where fentanyl is the most commonly used narcotic, we had never experienced such profound postoperative renarcotisation. The pharmacokinetics of sufentanil were found by Bovill et al. 3 to be similar to fertlanyl in having a three compartment open model characterised by triexponenttal decay. The third compartment acts as a reservoir, limiting return of the drug to the central compartment from which elimination is assumed to occur. Becker et at. 4 observed respiratory depression in the postoperative period after fentanyl anaesthesia. He found a consistent decrease in the slope of the carbon dioxide response curve. This in itself would not be surprising but these author~ 'also described a recurrence of respiratory depression in the recovery room, after normality had apparently been achieved. Following this report, secondary peaks in plasma fentanyl levels were subsequently observed. Stoeckel et al. ~ noted high initial plasma fentanyl concentrations following a bolus dose IV and in mony patients a secondary increase in plasma concentration was seen. McQuay et al. 6 demonstrated a second peak of fentanyl in the plasma of many patients. McClain and Hug 7 suggested that the cumulation and persistence of fentanyl may cause unexpectedly prolonged ventilatory depression. Recurrent respiratory depression might result from mobilisation of fentanyl from tissue stores and from reduced stimulation. The reeonm~ended induction dose of sufentanil for major surgery with an anticipated duration of two hours is 1_5-2.0 I~g-kg -1. Maintenance doses of 10-25 ~,g are given, based on changes in clinical signs. Total dose requirements should average l v,g' kg~. hrt Respiratory depression produced by a sufentanil dose of 25 la,g IV is said to last 25-30 minutes. Our patient received 2.6 ixg'kg -I for a 2.5-hour procedure, with the last increment being administered 120 minutes prior to the end of the procedure and 140 minutes before the respiratory arrest. The manufacturer of sufentanil warns: "Patients who arrive in the recovery room awake and alert may lapse into a sedated state with diminished breathing if left unstimulated." Our patient by comparison was comatose and apnoeic, presumably due to a secondary narcotic peak.

Respiratory arrest after recovery from anaesthesia supplemented with sufentanil