SOFT 2004 Meeting Abstracts - Society of Forensic Toxicologists
SOFT 2004 Meeting Abstracts - Society of Forensic Toxicologists
SOFT 2004 Meeting Abstracts - Society of Forensic Toxicologists
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P49 <br />
ALFENTANIL FATAL INJECTION: A CASE REPORT<br />
V.Dumestre-Toulet* I, M. Villain 2, P. Kintz 2<br />
ILaboratoire TOXGEN - Bordeaux; 2Institut de Medecine Legale - ChemTox - Strasbourg<br />
Introduction: We report a case <strong>of</strong> fatal intoxication with alfentanil (RAPIFEN,ALFENT A ampoules <strong>of</strong><br />
1 and 5 mg), an intravenous narcotic analgesic, chemically related to fentanyl and characterized by a very<br />
rapid onset and short duration <strong>of</strong> action. Alfentanil is used as an adjunct for surgical anaesthesia under<br />
assisted ventilation in medical units.<br />
Case-report: A 46-year-old anaesthetist male nurse was found dead in the toilets <strong>of</strong> an hospital. A syringe<br />
was found near the body. He was suspected <strong>of</strong> narcotic theft and abuse because a lot <strong>of</strong> ampoules were<br />
missing since several months in the unit. Autopsy findings revealed injection marks on the left ann, an<br />
oedematous and inflammatory aspect <strong>of</strong> various organs and a bilateral pulmonary oedema. Biological<br />
samples (blood, urine and hair) were collected and sent to the laboratory for forensic toxicological analysis.<br />
Methods: Screening analyses were performed by immunoassay, gas chromatography/mass spectrometry<br />
(GC/MS) and liquid chromatography/diode array detection (LCIDAD) using standardized methods <strong>of</strong> our<br />
laboratory. GC/flame ionisation detector with headspace injection (HS) was used to detennine blood<br />
alcohol concentration. Alfentanil and fentanyl were screened with GCIMS and quantification was<br />
performed with GC/MS/MS after liquid-liquid extraction with chlor<strong>of</strong>onn/2-propanol/heptane (33:17:50,<br />
v/v/v) and phosphate buffer (Iml, pH 9.5). Fentanyl d S was used as internal standard.<br />
Results: Alfentanil was identified in blood and urine at 45.1 and 2.7 nglml, respectively. Blood alcohol<br />
concentration was measured at 1.32 gil. Hair analysis revealed chronic use <strong>of</strong> alfentanil (2 pglmg) and<br />
fentanyl (8 pg/mg). No other drugs were detected.<br />
Adult surgical patients who received a bolus dose <strong>of</strong> 8 to 50 jlg/kg alfentanil by intravenous infusion<br />
developed plasma concentrations <strong>of</strong> 200 to 1000 nglml. Alfentanil is capable <strong>of</strong> producing severe<br />
respiratory depression with hypotension and coma during surgical operations even with assisted ventilation<br />
and plasmatic concentrations above 100 - 200 ng/ml (1). Whereas fentanyl is reported as a commonly<br />
abused substance by healthcare pr<strong>of</strong>essionals (2), alfentanil misuse and abuse seems exceptional (3).<br />
Conclusion: Although the measured concentrations are therapeutic, alfentanil injection without assisted<br />
ventilation may be the cause <strong>of</strong> the death. Hair analysis demonstrated chronic abuse <strong>of</strong> alfentanil and<br />
fentanyl by the anesthetist nurse.<br />
References:<br />
(1) Mahla ME, White SE, Moneta MD. Delayed respiratory depression after alfentanil. Anesthesiology<br />
1988 ; 69: 527-534<br />
(2) Villain M, Cirimele V, Ludes B, Kintz P. Toxicomanie d'un anesthesiste au fentanyl: la preuve<br />
fonnelle par analyse des cheveux en utilisant la CPG/SM/SM. Ann. Toxicol. Anal. 2001; 13 (1): 49<br />
53,<br />
(3) Kintz P, Villain M, Cirimele V, Ludes B. Conduites addictives en milieu hospitalier : particularites<br />
d'un service d'anesthesie. Ann. Toxicol. Anal. 2002; 14(1): 83- 89<br />
Keywords: alfentanil, chronic abuse, hair, GC/MSIMS.<br />
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