Accidental Intrathecal Morphine Overdose During the Surgery: A Case Report and Literature Review.

Neuraxial anesthetic techniques have become part of the multimodal analgesia approach for gynecologic surgeries. Specifically, intrathecal morphine is one of the opioids most commonly used for prolonged pain management postoperatively. However, doses above a certain threshold pose a greater risk of adverse effects, especially respiratory complications. This case highlights the challenges faced during the management of an accidental administration of a tenfold dose of morphine in the subarachnoid space for a patient subjected to major gynecologic surgery. Surprisingly, yet to our advantage, the patient exhibited no evidence of the anticipated adverse effects and no further intervention was required. A key indicator that was crucial in identifying the mistake was a diminution in the minimal alveolar concentration (MAC) of the anesthetic agent used.