Décès d'un chirurgien par rémifentanil, fentanyl et midazolam : explorations toxicologiques

Deaths due to self-administration of intravenous anesthetic/narcotic agents are rare because this type of products is difficult to obtain. Most of the cases are observed in hospitals or among hospital workers. Manner of death reported for such cases is suicide for a large majority but the potent respiratory depressant effect of the drugs can also lead to accidental deaths. A 31-year-old male was found in cardio-respiratory arrest in the toilet of a hospital. He was immediately taken to intensive care unit where resuscitation was attempted during 45 minutes. The day after the death, autopsy was performed and revealed multiple fresh and older puncture marks on the thighs and arms. After autopsy, our laboratory received multiple biological samples (peripheral and cardiac blood, urine, vitreous humor, hair). Various chromatographic techniques were used to execute large unknown screenings and to quantitate the drugs present in biological samples. Toxicological analysis of peripheral blood revealed the presence of remifentanil, fentanyl, midazolam, tramadol, codeine, and amiodarone. Analysis of remifentanil was performed in peripheral and cardiac blood, urine, vitreous humor and hair. Remifentanil is a very short acting fentanyl analogue rapidly metabolized by esterases. Due to its very short half-life of 6 to 16 min, remifentanil is almost never found in postmortem blood. Remifentanil can cause death even at therapeutic levels if not administered properly. To the best of our knowledge, this is the first report of a concentration of remifentanil in postmortem blood.