A 50-year-old breast cancer patient suffered a severe perioperative anaphylactic reaction during an attempted quadrantectomy and sentinel lymph node biopsy, Cureus reported. The medical team documented sudden hypotension, extreme thoracic rigidity, bronchospasm, and a generalized erythematous rash within minutes of anesthetic induction on day zero.
Severe Respiratory and Cardiovascular Collapse During Induction
The patient weighed 50 kg and presented with American Society of Anesthesiologists physical status II, alongside a documented history of allergic asthma. At approximately 12:20 on day zero, clinicians administered 2 g of ceftriaxone intravenously for surgical prophylaxis. Induction commenced at 12:35 with 2 mg of midazolam, 100 mg of propofol, 100 µg of fentanyl, and 40 mg of rocuronium, followed by endotracheal intubation and maintenance with sevoflurane.
Within minutes, the patient experienced a blood pressure drop to a nadir of approximately 75-80/40 mmHg, tachycardia reaching 110 beats per minute, and a peripheral oxygen saturation drop to 70%. An arterial blood gas sample collected at 12:59 revealed a pH of 7.164 and a partial pressure of arterial carbon dioxide of 69.5 mmHg. Clinicians administered three intravenous epinephrine boluses of 50 µg, inhaled salbutamol, hydrocortisone, chlorphenamine, and methylprednisolone. Following stabilization, the surgical procedure was postponed, and the patient transferred to the intensive care unit intubated and sedated.
Clinicians Administer Rocuronium Infusion During Intensive Care Unit Management
Intensive care unit care involved pressure-controlled ventilation, propofol sedation, and a continuous intravenous salbutamol infusion. To maintain neuromuscular blockade, clinicians administered a rocuronium infusion at 30 mg/h beginning at 15:00, totaling approximately 105 mg over three and a half hours. This re-exposure occurred prior to any formal allergy investigation.
Drug Skin Testing Reveals Positive Results for Midazolam and Rocuronium
Drug skin testing on day fourteen revealed positive results for midazolam at 0.5 mg/mL and rocuronium at 0.05 mg/mL, according to the Cureus report.
The rocuronium test utilized the recommended European Academy of Allergy and Clinical Immunology intradermal concentration. However, the midazolam concentration of 0.5 mg/mL matched ten times the current European Academy of Allergy and Clinical Immunology maximum non-irritant intradermal limit of 0.05 mg/mL, raising the possibility of an irritant false positive. Acute and baseline serum tryptases were not measured during or after the reaction.
Safe Subsequent General Anesthesia on Day Twenty-Eight
The patient was readmitted on day 26 and successfully underwent right breast quadrantectomy with sentinel lymph node biopsy on day 28. Following allergy service recommendations, clinicians avoided midazolam, neuromuscular blocking agents, and beta-lactams.
Anesthesia utilized propofol, fentanyl, and sevoflurane. The airway was secured without a neuromuscular blocking agent. The procedure and subsequent recovery proceeded without adverse events.
Frequently Asked Questions About Perioperative Anaphylaxis
What caused the anaphylactic reaction during the initial surgery?
The medical team could not isolate a single culprit because multiple drugs were administered within minutes at induction. Skin tests returned positive for both rocuronium and midazolam, though the midazolam concentration exceeded current non-irritant guidelines.
Why was rocuronium administered again in the intensive care unit?
Clinicians administered a rocuronium infusion for mechanical ventilation before the allergy work-up took place. The patient did not experience a renewed reaction during this infusion, though deep sedation and high-dose corticosteroids may have masked clinical signs.
How was the subsequent breast cancer surgery performed safely?
On day 28, clinicians successfully completed the quadrantectomy by entirely avoiding midazolam, neuromuscular blocking agents, and beta-lactams. Propofol, fentanyl, and sevoflurane were used without complication, clinically confirming earlier negative skin test results.
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