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Syringe pumps are especially useful because they are easy to prepare and convenient when small volumes of liquid medications need to be infused over a relatively long duration [1]. Despite the use of syringe pumps in everyday practice, the safe use of infusion devices is often overlooked by medical staff. Numerous hazards of infusion pumps have been reported [1–3]. The requirement for patient consent was waived by the Institutional Review Board of our institution (H-2003-019-089). A 32-year-old healthy pregnant woman was scheduled for emergency cesarean section. She was at 37+5 weeks of gestation and had undergone cesarean section four years ago. The preoperative examinations revealed normal results. After providing informed consent for anesthesia, the patient entered the operation room, and routine monitoring was performed. Her vital signs were stable. An anesthesia nurse installed a 20-ml syringe containing remifentanil (0.1 mg/ml) on a syringe pump (Injectoma TIVA Agilia®, Fresenius Kabi, Germany) and connected it to an intravenous line via a three-way stopcock. The syringe pump was powered off because the patient needed to be sterilized and draped before the induction of anesthesia. After a few minutes, the patient closed her eyes, and an anesthesiologist asked her to open her eyes to confirm consciousness. She opened her eyes immediately but closed them soon again. Then, upward ocular deviation occurred. She did not respond to any command and became apneic. Flat capnography was observed and the Bispectral index fell to 75 at the same time. Then, SpO2 dropped to 89%, and mask bagging with 100% O2 was started. At that time, her blood pressure and heart rate were 99/56 mmHg and 75 beats/min, respectively, and SpO2 was quickly recovered to 100% after applying mask ventilation. We attempted to determine the reason for her unconsciousness and checked the syringe pump. A crack in the syringe was noted, through which air bubbles had entered and pushed the remifentanil solution into the patient (Fig. 1, Video 1). We immediately disconnected the remifentanil solution from the patient’s intravenous line. Consequently, only 10 ml of remifentanil solution remained in the syringe. After a brief notice to the obstetrician, 250 mg of thiopental sodium and 40 mg of rocuronium were injected. Tracheal intubation was performed without difficulty, and 5 min later, a male baby was delivered. No other notable events occurred during the remaining intraoperative period. The patient and her baby were discharged a week later. After the events, the distribution and storage of the syringe were investigated, but there were no problems. We tested 10 more syringes installed in the same syringe pump, and all of them were similarly damaged. Also, the syringes were not damaged in other syringe pumps of the same model. The syringe pump was sent to the department of bioengineerReceived: July 20, 2020 Revised: July 30, 2020 Accepted: July 31, 2020

Inadvertent free flow of remifentanil caused by a damaged syringe installed in syringe pump