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Ischaemic lesions related to pressure from the bindings of a wrist splint and cardiopulmonary bypass

flumazenil indicated that these were due, at least in part, to the effect of midazolam. This is surprising because only a total of 2.4 mg midazolam was administered over 2 hours. This is a very small dose compared with that normally administered intravenously or intramuscularly and indicates again that these actions were probably the result of a supraspinal spread of the drug away from the site of application via the cerebrospinal fluid. This would cause a much higher receptor occupancy in the brain than would occur after intravenous administration. The facts of this case therefore are that all the observed effects of the inadvertent administration of these two drugs epidurally may be explained by supraspinal effects of both drugs. The residual analgesia might have been caused by supraspinal effects of fentanyl that remained after the small dose of naloxone had been administered. Unlike intrathecal administration (we routinely use a 2mg bolus intrathecally) epidural administration of midazolam is accompanied by considerable sedation, as the report by Stedman and Hammond confirms. The epidural route may be preferred to the intrathecal route if this sedation can be reversed with small doses of flumazenil but a spinal analgesic block be retained. We recommend that investigators define dermatomal levels of analgesia in order to be sure that they study spinally mediated analgesia and not merely a partially reversed supraspinal effect.