Persistent overdose caused by a very small dose of intrathecal morphine in an elderly patient undergoing vaginal hysterectomy: a case report

Intrathecal opioid administration is a well established, inexpensive and effective, widely used procedure in the elderly and has well known side effects. We report a case of an elderly woman who received small doses of intrathecal opioids (sufentanil 2.5 microg and morphine 60 microg) for gynecological surgery and thereafter developed severe neurological side effects. She required prolonged treatment with very high doses of naloxone (16 mg).