Massive Clonidine Overdose During Refill of an Implanted Drug Delivery Device for Intrathecal Analgesia: A Review of Inadvertent Soft-Tissue Injection During Implantable Drug Delivery Device Refills and Its Management

摘要: Objectives.  The study aims to highlight the potentially serious consequences of inadvertent soft-tissue injection intrathecal drugs such as clonidine, during refills implanted drug delivery devices, and suggest strategies reduce this complication. Design.  Case report literature review were used. Results.  We case a 51-year-old female with chronic arm pain who sustained massive clonidine overdose (18,000 mcg) due refill an device, resulting in rapid loss consciousness significant cardiovascular instability requiring urgent resuscitation, subsequent myocardial infarction, cardiac failure, other complications. risks device management events is poorly documented literature. Conclusion.  Inadvertent possibly underappreciated underreported complication analgesia via device. Under some circumstances, large doses bupivacaine, opioids, ziconotide, baclofen may also be delivered by life-threatening consequences. recommend that practitioners, institutions, professional bodies manage patients devices audit develop systems it.