Septic shock in the operating room immediately after surgery: a case requiring differentiation from drug-induced anaphylaxis

There are few reported cases of sepsis becoming apparent in the operating room, and even fewer where septic shock was misdiagnosed as anaphylaxis. Here, we report a case of septic shock occurring during extubation immediately after elective abdominal surgery, highlighting the need to differentiate septic shock from drug-induced anaphylaxis.

A 72-year-old woman underwent elective extended left hepatic lobectomy under combined general and epidural anesthesia. Although cholangitis was suspected before surgery, her symptoms improved with treatment, allowing the planned procedure to proceed. Shortly after administration of sugammadex during extubation, she developed severe hypotension and generalized erythema, raising the suspicion of anaphylaxis. However, laboratory findings later revealed elevated procalcitonin and positive blood cultures for Klebsiella pneumoniae, consistent with septic shock. The patient recovered after treatment for sepsis, and was discharged without complications. Serum tryptase and histamine levels were not elevated, and subsequent skin tests for suspected anaphylaxis-inducing drugs were negative. She later uneventfully underwent another surgery using the same anesthetic agents.

We report a case that initially mimicked drug-induced anaphylaxis, but was ultimately diagnosed as septic shock. This serves as a crucial reminder for clinicians to maintain a high index of suspicion for septic shock in the perioperative setting, even when the initial presentation strongly suggests an allergic reaction.