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    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. Under some circumstances, large doses of other intrathecal drugs such as bupivacaine, opioids, ziconotide, and baclofen may also be delivered by inadvertent soft-tissue injection with potentially life-threatening consequences. The risks of inadvertent soft-tissue injection of intrathecal drugs during implanted drug delivery device refills and management of such events is poorly documented in the literature. Inadvertent soft-tissue injection is possibly an underappreciated and underreported complication of intrathecal analgesia via an implanted drug delivery device. 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. We recommend that practitioners, institutions, and professional bodies who manage patients with intrathecal analgesia via intrathecal drug delivery devices highlight and audit this complication and develop systems to manage it. A 51-year-old female (66 kg, 157 cm) with a 10-year history of complex regional pain syndrome (CRPS) type I of the right arm underwent routine refilling of an abdominal wall (subcutaneous) implanted drug delivery device (IDDD) (Synchromed EL® Model 8627; Medtronic, Minneapolis, MN, USA: 18-m L reservoir) by a medical practitioner at a remote, local hospital. The IDDD was refilled with clonidine 18,000 mcg (1,000 mcg/m L) and morphine 90 mg (5 mg/m L) in 18 m L of 0.9% saline for intrathecal (IT) analgesia, programmed to deliver 0.2 m L per day (clonidine 200 mcg/morphine 1 mg). The practitioner had performed the refill procedure on numerous occasions and reportedly used the manufacturer's “refill kit” equipment. CLONIDINE 0.025MG - ORAL side effects, medical uses, and Clonidine poisoning, the lethal dose for humans CLONIDINE - National Library of Medicine HSDB Database
     
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