1例59岁乳腺癌患者,因腰背部疼痛加剧,给予芬太尼透皮贴剂1贴(8.4 mg)。30 min后患者入睡,持续约4 h患者突然出现意识丧失,头向后上仰,颈项强直,四肢抽搐,双侧瞳孔缩小,对光反射迟钝,呼吸深、慢(6～7次/min),脉搏血氧饱和度下降至0.77。考虑和芬太尼过量有关。立即去除芬太尼透皮贴剂,给予吸氧,静脉注射纳洛酮0.2 mg。之后,患者四肢抽搐缓解,呼吸升至18次/min,意识恢复,无肢体感觉、运动功能障碍。 A 59-year-old breast cancer patient was given a patch of fentanyl transdermal patch (8.4 mg) due to increased lower back pain. After 30 min, the patient fell asleep and lasted for about 4 hours. Sudden loss of consciousness, head backwards, stiff neck, twitching limbs, bilateral miosis, slow light reflex, deep and slow breathing (6-7 times / min) , Pulse oximetry decreased to 0.77. Consider overdose of fentanyl. Immediate removal of fentanyl transdermal patches, given oxygen, intravenous injection of naloxone 0.2 mg. Later, the patient’s limb twitch relief, breathing rose to 18 beats / min, consciousness recovery, no physical feeling, motor dysfunction.