Accidental intrathecal administration of high dose Diamorphine

A case of accidental administration of high dose intrathecal diamorphine is reported in a patient who underwent total knee replacement. Initially a regional technique was planned for this patient, but due to inadvertent administration of three milligrams of diamorphine intrathecally, it was decided to convert the patient to have a general anaesthetic. Postoperatively, she was monitored in high dependency unit for 48 hours. Apart from two episodes of nausea and mild drowsiness, she did not develop any serious side effects and did not require naloxone.