Should Postmortem Subclavian Blood be Considered a Peripheral or Central Sample?

Case report on postmortem fentanyl measurement after overdose with more than 67 fentanyl patches

Purpose

Fentanyl is an analgesic that is frequently prescribed, which resulted in non-intentional as well as intentional misuse and deaths. Here, we present a postmortem case of a patient who clearly died of a fentanyl overdose due to an extensive number of fentanyl patches combined with oral intake of fentanyl and cocaine. We aimed to show how postmortem analysis can be used to interpret postmortem fentanyl concentrations in unique cases like the one we present.

Case description

A 23-year-old male was found dead in his bedroom with 67 non-prescribed patches of fentanyl on his body. In the room, there also were fentanyl tablets of 100 µg and cocaine powder, which had possibly also been taken by the deceased. To confirm the cause of death, urine and subclavian blood were retrieved to perform a standard postmortem toxicology screening. The toxicological screening revealed the presence of several drugs, including cocaine, fentanyl, lidocaine and paracetamol. Further analysis of the quantitative postmortem values of fentanyl with ultra-performance liquid chromatography-tandem mass spectrometry revealed a fentanyl concentration of 57.9 µg/L. Considering several issues around postmortem drug analyses, this value seemed to be in line with concentrations found in previously reported postmortem cases.

Conclusion

We were able to confirm the expected cause of death with an extensive toxicological screening in combination with the circumstantial evidence. We identified fentanyl as most important cause for the fatal outcome in this specific case and simultaneously contributed to the limited availability of knowledge on postmortem fentanyl concentrations.

Postmortem Ethanol Concentrations and Postmortem Ethanol Production

A review of the literature was conducted in reference to postmortem blood ethanol concentrations and the issue of postmortem production of ethanol. Ethanol in postmortem specimens may occur as a result of antemortem consumption (most common), postmortem production in the body or in vitro by microorganisms (less common), and endogenous production by microorganisms during life (rare). The portion of ethanol-positive postmortem cases in which postmortem production of ethanol is thought to have occurred is small, as is the portion of cases in which postmortem production of ethanol is a potentially important issue. It is unusual for postmortem production of ethanol to account for more than a 70 mg/dL concentration, but cases with higher concentrations occasionally occur. Cases in which blood ethanol is positive but vitreous ethanol concentration is much lower or negative, and/or in which the urine: blood ethanol concentration ratio is less than one are supportive of postmortem ethanol production. The presence of other alcohols such as n-propanol and/or n-butanol is suggestive of postmortem microbial production of ethanol. The ratio of serotonin metabolites in urine may be helpful in distinguishing postmortem production of ethanol from antemortem consumption, as may the concentration of ethyl glucuronide in blood. Candida and some other species may produce ethanol in urine antemortem and postmortem. In rare instances such as infections, endogenous ethanol production may occur in a living person. Recommendations are made concerning samples to collect and tests that may be helpful in distinguishing antemortem ethanol consumption from postmortem production of ethanol.