Anaphylactic Shock During Oculofacial Plastic Surgery in a Patient With Midazolam and Tetracaine Allergies

Anaphylactic shock is a rare but life-threatening perioperative emergency characterized by bronchospasm, hypoxia, and hypotension. A 56-year-old woman underwent elective oculofacial plastic surgery and developed anaphylactic shock shortly after exposure to tetracaine eye drops; intravenous sedation with midazolam and propofol; and a local anesthetic mixture of lidocaine, bupivacaine, and epinephrine. Initial signs included facial flushing, hypotension, and oxygen desaturation. Intubation, epinephrine, steroid, and intensive care unit transfer were required. Blood tryptase drawn 2.5 hours after the onset of symptoms was within normal range, but subsequent allergy testing revealed positive reactions to both midazolam and tetracaine. The patient fully recovered and was discharged the following day. She underwent successful surgery 6 months later under general anesthesia. This case underscores the importance of early recognition of anaphylactic shock and the necessity of procedure rooms being well equipped to intervene. Vigilance is necessary even with agents not commonly associated with anaphylactic shock.