When Safety Barriers Fail: Paracetamol-Induced Anaphylaxis Under General Anesthesia Despite Multiple Allergy Warnings
Abstract
Intravenous paracetamol-induced anaphylaxis is uncommon but can be life-threatening during general anesthesia. The principal lesson of this case, however, was not the allergic reaction itself but the failure of multiple perioperative safety barriers that allowed the administration of a suspected allergen. We report the case of a 50-year-old woman who developed circulatory collapse, with systolic blood pressure decreasing from approximately 100 mmHg to 60 mmHg before becoming unmeasurable, approximately five minutes after inadvertent intravenous paracetamol administration during breast surgery under general anesthesia. Paracetamol had been identified preoperatively as a suspected allergen, documented by multiple healthcare professionals, recorded on handwritten anesthesia documents, and displayed prominently in the operating room. However, this information was not transformed into shared situational awareness or effective team action. The attending locum anesthesiologist was unable to access the electronic medical record (EMR) before anesthesia induction, and intravenous paracetamol remained available in the operating room despite institutional policy requiring removal or clear identification of suspected allergenic drugs. Prompt treatment with epinephrine, fluid resuscitation, vasopressors, and adjunctive anti-allergic medications resulted in complete recovery without neurological sequelae. Elevated serum histamine and β-tryptase concentrations, together with postoperative…
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