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.

Objectives: The study aims to highlight the potentially serious consequences of inadvertent soft-tissue injection of intrathecal drugs such as clonidine, during refills of implanted drug delivery devices, and to suggest strategies to reduce this complication.

Design: Case report and literature review were used.

Results: We report the case of a 51-year-old female with chronic arm pain who sustained a massive clonidine overdose (18,000 mcg) due to inadvertent soft-tissue injection during a refill of an implanted drug delivery device, resulting in rapid loss of consciousness and significant cardiovascular instability requiring urgent resuscitation, subsequent myocardial infarction, cardiac failure, and other significant complications.