60 https://www.id-press.eu/mjms/index Scientifc Foundation SPIROSKI, Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. 2020 May 11; 8(C):60-62. https://doi.org/10.3889/oamjms.2020.3774 eISSN: 1857-9655 Category: C - Case Reports Section: Case Report in Internal Medicine Anaphylactic Shock Due to Atracurium in a Patient Underwent General Anesthesia Christopher Ryalino*, Otniel Adrians Labobar, Made Wiryana, I. Ketut Sinardja, Tjokorda Gde Agung Senapathi, Adinda Putra Pradhana Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Bali, Indonesia Abstract BACKGROUND: Anaphylaxis is a systemic hypersensitivity reaction marked by life-threatening, rapid onset of the airway, breathing, and circulation problems. Despite its rare incidence, without proper treatment, it may cause fatality. CASE REPORT: In this report, we present a 19-year-old female with an infected ovarian cyst, who was scheduled for gynecologic laparotomy. In pre-operative assessment, she was classifed as an American Society of Anesthesiologist (ASA) one patient without any history of drug or food allergy. Hemodynamic changes occurred on anesthesia induction after the administration ofatracurium, a muscle relaxant agent. Marked clinical signs were wheezed- bronchospasm, dyspnea, hypersalivation, desaturation, tachycardia, hypotension, and systemic erythema. She was diagnosed with anaphylactic shock. We provided 100% oxygenation, fuid resuscitation, epinephrine, and supportive therapy by anaphylaxis guidelines. Respiratory and cardiovascular functions stabilized 2 h post-resuscitation. The surgery was canceled, and she was observed in ICU for 24 h. CONCLUSION: Timely diagnosis and early resuscitation are key factors determining the outcome of an anaphylactic reaction. Edited by: Ksenija Bogoeva-Kostovska Citation: Ryalino C, Labobar OA, Wiryana M, Sinardja IK, Senapathi TGA, Pradhana AP. Anaphylactic Shock Due to Atracurium in a Patient Underwent General Anesthesia. Open-Access Maced J Med Sci. 2020 May 11; 8(C):60-62. https://doi.org/10.3889/oamjms.2020.3774 Keywords: Atracurium; Anaphylaxis; Perioperative; Epinephrine *Correspondence: Christopher Ryalino, Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232, Bali, Indonesia. E-mail: ryalino@unud.ac.id Received: 24-Sep-2019 Revised: 20-Jan-2020 Accepted: 28-Feb-2020 Copyright: © 2020 Christopher Ryalino, Otniel Adrians Labobar, Made Wiryana, I. Ketut Sinardja, Tjokorda Gde Agung Senapathi, Adinda Putra Pradhana Funding: This research did not receive any fnancial support Competing Interests: The authors have declared that no competing interests exist Open Access: This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 International License (CC BY-NC 4.0) Introduction Anaphylaxis is a severe, life-threatening systemic hypersensitivity reaction that is characterized by the emergence of life-threatening airway, respiratory, and circulatory problems with rapid onset and is usually associated with changes in the skin and mucosa [1]. Its prevalence ranges from 1:3,500 to 1:13,000 [2]. Overall, anaphylaxis has a good prognosis, with a case fatality ratio of <1%. The risk of death is increased in patients with asthma, especially in uncontrolled asthma [3]. Anaphylactic reactions are generally unpredictable allergic reactions, which occur very quickly, which can arise especially during surgery due to varying drug administration. The diagnosis of anaphylaxis in the perioperative period is still a challenge for the anesthesiologist. A study reported that of the 42 anesthesia teams tested by simulators, none was able to identify anaphylaxis in the frst 10 min. [2], [4]. Case Illustration A 19-year-old woman, 55 kg, was planned for laparotomy surgery due to an infected left ovarian cyst. A day before the surgery, detailed history, physical examinations, and investigations were carried out. There was no history of allergy to drugs or food, no history of asthma, and no history of the previous surgery. There were no marked abnormalities in physical or supporting examinations. She was planned for general anesthesia with the insertion of the orotracheal tube. She received cefotaxime 1 g and metronidazole 500 mg as prophylactic antibiotics an hour before surgery and was premedicated with dexamethasone 5 mg and midazolam 2 mg. After induction with 75 mcg fentanyl and 100 mg propofol intravenously, she still showed stable hemodynamic conditions. To facilitate intubation, we administered intravenous atracurium 25 mg. One minute after the administration of atracurium, we noticed hypersecretion in her airway. She then developed wheezing sounds and difculty to ventilate the airway. Saturation was decreased to 80% despite 100% O 2 being given, followed by marked erythema developed in most parts of the skin, hypotension (BP 67/33 mmHg), and tachycardia (HR 134–138 bpm). Anaphylaxis shock was diagnosed. We immediately performed intubation to maintain the airway – positive pressure ventilation with 100% FiO 2 oxygen. Epinephrine 0.5 mg was given intramuscularly, and dexamethasone 5 mg was administered intravenously.