Suicide with remifentanil and midazolam: a case report.

BACKGROUND: Remifentanil (Ultiva) is a recently introduced esterase-metabolized potent opioid (EMO) mu-receptor agonist with a rapid onset and offset of action for use as part of general anaesthesia in association with isoflurane or propofol or with midazolam (Dormicum) and in combination with mivacurium.

CASE REPORT: A nurse from the anaesthesiology department of a hospital was found dead at home with a syringe and empty vials of Ultiva (2 mg) and of Dormicum (1 mg/mL). At autopsy several injection sites were found on her body. Usual toxicology screening operated in our laboratory revealed only the presence of benzodiazepines in blood. Regarding the case history, we decided to adapt a method specially designed for remifentanil and its inactive metabolite testing. The analytes were isolated by SPE on a Clean-Screen column. After silylation with BSTFA with 1% TMCS, the analytes were detected by GC/MS-EI operating in the SIM mode. No Remifentanil could be detected, whereas the metabolite of remifentanil GR90291 was determined in femoral blood, liver, kidney and lung. Furthermore, midazolam could be detected in femoral and cardiac blood. Hair analysis of a segment of 5 cm revealed the presence of diazepam and midazolam, whereas neither remifentanil nor its metabolite could be detected.