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Akbari H, Ghahremani-Chabok A, Mousavi S A. Inadvertent Subcutaneous Injection of Atracurium During Circumcision Operation. J. Pediatr. Rev 2020; 8 (1) :53-58
URL: http://jpr.mazums.ac.ir/article-1-234-en.html

Introduction: Neuromuscular blocking agents relax skeletal muscles relaxation operation or mechanical ventilation. Accidental injection of these agents is a medical error which can lead to a minor sequel or devastating complications. We report an inadvertent subcutaneous injection of atracurium in circumcision operation and also briefly review the international databases related to the reported case.
Case Presentation: A two month-old infant was scheduled for circumcision under local anesthesia. Five minutes after subcutaneous injection of atracurium instead of lidocaine for local anesthesia, the patient developed respiratory apnea, cyanosis, muscle relaxation, and bradycardia. Then the patient was intubated and transferred to the Neonatal Intensive Care Unit (NICU) to receive supportive care and kept under follow up. After taking supportive and therapeutic cares, there was no complication. The patient, after complete recovery, was discharged without any problems.
Conclusion: Despite all efforts to prevent medical errors, they can happen. Reporting these cases highlights the importance of early diagnosis of errors, correcting therapeutic interventions, and delivering accurate management of conditions for control and elimination of symptoms and complications.