ABSTRACT
This report relates how tracurium was given by mistake, intrathecally, during spinal anesthesia, to a 38-year-old woman, who was a candidate for abdominal hysterectomy. When no analgesia was observed, the mistake in giving the injection was understood. She was evaluated postoperatively by train of four ratio, measuring her breathing rate, eye opening, and protruding of tongue at one, two, twenty-four, and forty-eight hours, and then at one and two weeks, with the final evaluation the following month. The patient had normal timings during the operation and postoperation periods, and no abnormal findings were observed through the first month. This finding was contrary to several studies, which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs.
