Background: In sugammadex-induced anaphylaxis, sugammadex and/or sugammadex-rocuronium complex have possible allergenic epitope. Case: We report a case of sugammadex-induced anaphylaxis during general anesthesia in a 60-year-old male undergoing orthopedic hand surgery, manifesting as profound hypotension and urticaria. The timing of onset was closely associated with sugammadex administration. The patient recovered after extensive therapy including fluid, epinephrine, other vasopressors, steroid, and antihistamine administration. By intradermal skin test which was done at four weeks after anaphylaxis, we confirmed positive reactions to both sugammadex and sugammadex-rocuronium complex. Conclusions: This is a rare case of sugammadex-induced anaphylaxis that both sugammadex and sugammadex-rocuronium complex were confirmed as allergenic epitopes.

Rationale: Neurally mediated reflexes can induce cardiac arrest during head and neck surgery through mechanisms including direct vagal stimulation, trigeminocardiac reflex, and baroreceptor reflex. Balloon dilation of the Eustachian tube (BDET) is a safe procedure without serious complications, including cardiac arrest.Patient concerns: Transient asystole developed during BDET under general anesthesia in a 33-year-old woman as soon as the balloon in the Eustachian tube (ET) was inflated.Diagnoses: Monitoring records were reviewed. The asystolic period was recorded on the patient monitor as an event, which we recalled and printed. The asystole lasted for 13 seconds.Interventions: The patient recovered sinus rhythm spontaneously after the balloon was deflated before resuscitation. The BDET was successfully performed after prophylaxis with vagolytic drugs.Outcomes: The patient recovered uneventfully after anesthesia.Lessons: BDET, previously known to be a relatively safe procedure, induces asystole via balloon dilation. It is thought to be a neurally mediated vagal reflex, and both anesthesiologists and otologic physicians should pay proper attention to monitoring during the procedure.Abbreviations: BDET = balloon dilation of the Eustachian tube, ETD = Eustachian tube dysfunction.

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