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Pain Res Manag


Serious Adverse Events after a Single Shot of Intrathecal Morphine: A Case Series and Systematic Review.


Koning MV, Reussien E, Vermeulen BAN, Zonneveld S, Westerman EM, De Graaff JC, Houweling BM
Pain Res Manag. 2022; 2022:4567192.
PMID: 35311036.


The dose of intrathecal morphine is important because of its narrow therapeutic range. Due to a compounding error, pharmacy-compounded, ready-to-use syringes contained 1 mg ml morphine instead of the intended 50 mcg ml. Six patients consequently received this twenty-fold dose. This study aims to describe the serious adverse events in these six patients and a systematic review is added to describe the characteristics of serious adverse events after intrathecal morphine.