A suspected case of rocuronium–sugammadex complex-induced anaphylactic shock after cesarean section

Yamaoka, Masakazu; Deguchi, Miki; Ninomiya, Kiichiro; Kurasako, Toshiaki; Matsumoto, Mutsuko

doi:10.1007/s00540-016-2280-4

Cited by 38 publications

(30 citation statements)

References 17 publications

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“…There are several reports of sugammadex-induced hypersensitivity or anaphylaxis [ 55 – 61 ]. There are reports that not only sugammadex itself but rocuronium-sugammadex complex could be the trigger of anaphylactic reactions [ 59 , 61 ]. The most frequent symptoms of sugammadex-induced anaphylaxis are rash, hypotension and tachycardia.…”

Section: Reviewmentioning

confidence: 99%

Preparing for the unexpected: special considerations and complications after sugammadex administration

et al. 2017

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Sugammadex, a modified gamma-cyclodextrin, has changed clinical practice of neuromuscular reversal dramatically. With the introduction of this selective relaxant binding agent, rapid and reliable neuromuscular reversal from any depth of block became possible. Sugammadex can reverse neuromuscular blockade without the muscarinic side effects typically associated with the administration of acetylcholinesterase inhibitors. However, what remained unchanged is the incidence of residual neuromuscular blockade. It is known that sugammadex cannot always prevent its occurrence, if appropriate dosing is not chosen based on the level of neuromuscular paralysis prior to administration determined by objective neuromuscular monitoring. Alternatively, excessive doses of sugammadex administered in an attempt to ensure full and sustained reversal may affect the effectiveness of rocuronium in case of immediate reoperation or reintubation. In such emergent scenarios that require onset of rapid and reliable neuromuscular blockade, the summary of product characteristics (package insert) recommends using benzylisoquinolinium neuromuscular blocking agents or a depolarizing agent. However, if rapid intubation is required, succinylcholine has a significant number of side effects, and benzylisoquinolinium agents may not have the rapid onset required. Therefore, prior administration of sugammadex introduces a new set of potential problems that require new solutions. This novel reversal agent thus presents new challenges and anesthesiologists must familiarize themselves with specific issues with its use (e.g., bleeding risk, hypermagnesemia, hypothermia). This review will address sugammadex administration in such special clinical situations.

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Section: Reviewmentioning

confidence: 99%

Preparing for the unexpected: special considerations and complications after sugammadex administration

et al. 2017

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“…Anaphylactic reactions have been reported after the use of sugammadex. 11,12 Allergic reactions are typically associated with tachycardia, hypotension, generalised erythema, and bronchospasm because of histamine release. High tryptase concentrations are indicative of life-threatening allergic reactions and are not affected by CPR.…”

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confidence: 99%

Severe bradycardia and asystole after sugammadex

Bhavani¹

2018

British Journal of Anaesthesia

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EditordSugammadex, a modified g-cyclodextrin, has been increasingly used for antagonising rocuronium and vecuroniuminduced neuromuscular block. 1,2 The efficacy and safety of sugammadex has been well established. 3 A recent Cochrane review noted that use of neostigmine is associated with a higher risk of adverse events compared with sugammadex (28% vs 16%, respectively). 4 The risk of significant adverse outcomes such as residual paralysis, hypersensitivity and allergic reactions, postoperative nausea and vomiting, and bradycardia was also lower with sugammadex than neostigmine. However, the incidence of serious adverse events was similar between sugammadex and neostigmine at~1%. 4 We present two cases of significant bradycardia and asystole after sugammadex administration in patients undergoing gastrointestinal endoscopic procedures with the use of carbon dioxide for bowel insufflation to highlight this significant adverse outcome. The requirement for consent was waived for both patients.The first patient was a 41-yr-old, 72 kg male with small cell carcinoma of the lung and metastases to lymph nodes, bone, lung, and peritoneum who presented with a recent onset of increasing nausea and vomiting (5 days) and difficulty in swallowing liquids more than solids. He had recently completed his chemotherapy regimen (carboplatin and pemetrexed) and palliative radiotherapy to the right scapula and spine and was started on immunotherapy (dasatinib, denosumab and nivolumab), and had been hospitalised 16 days before this admission with evidence of obstructive pneumonia; he underwent bronchoscopy, and was treated with antibiotics. He had evidence of enlarged mediastinal lymph nodes that were considered to be non-obstructive. He had severe shortness of breath on minimal exertion, and there was concern (by his primary team) about aspiration as the cause. He did not have evidence of cardiac or neurological involvement. Given his age and the absence of other cardiac risk factors, no pre-procedure cardiac tests were carried out. Computerised tomographic examination of his chest suggested non-specific patulous oesophageal dilatation in addition to consolidation of the right middle and lower lobes. Vital signs were unremarkable except for a heart rate of 108 beats min À1 . The patient was scheduled for elective endoscopic gastro-duodenoscopy. Anaesthesia was induced with propofol 100 mg, succinylcholine 70 mg, and lidocaine 50 mg i.v. After tracheal intubation, anaesthesia was maintained with sevoflurane 0.8 MAC and titrated to effect. The patient received a single dose of rocuronium 20 mg during the course of the procedure after recovery from succinylcholine. His intraoperative course was uneventful, and ventilation was adjusted to maintain normocapnia. At the end of the procedure, he had a train-offour response of 2 with stimulation of the ulnar nerve. Reversal of the neuromuscular blocking agent after reduction of sevoflurane to an expired concentration of~0.1 MAC was accomplished with sugammadex 300 mg, followed by extubation. Ap...

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“…Little is currently known about the mechanism of sugammadex‐induced anaphylaxis due to the lack of sugammadex‐specific IgE antibodies available for testing, and skin prick tests for the drug are still in development. Emerging case reports in the literature lacked previous exposure to sugammadex, suggesting cross‐reactivity between sugammadex and another substance including a suspected case of anaphylaxis to the rocuronium‐ sugammadex complex …”

Section: Anaphylaxismentioning

confidence: 99%

An update on allergy and anaphylaxis in pediatric anesthesia

Stepanovic

Sommerfield

Lucas

et al. 2019

Pediatric Anesthesia

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Childhood allergy is common, and increasing. Many children are incorrectly labeled as having allergy or adverse drug reactions. This can pose a dilemma for anesthetists and lead to a change in practice or drug selection. We review the pathophysiology of hypersensitivity reactions and the implications for anesthesia of food allergy, atopy, and family history of allergy in children. The epidemiology of anaphylaxis is discussed. We discuss the common triggers of perioperative anaphylaxis in children and explore emerging triggers including chlorhexidine and sugammadex. Accurate data on pediatric perioperative anaphylaxis is limited worldwide, with marked geographic variation. This highlights the need for accurate local, district and/or nationwide incident reporting. The clinical features, diagnosis, and management of anaphylaxis under anesthesia are discussed. We review the process of expert allergy testing following a suspected case of anaphylaxis to guide future safe anesthesia administration. The preoperative consultation is an opportunity for referral for allergy testing to allow de‐labeling. This has the potential for improved antibiotic stewardship and more effective treatment with first‐line therapeutic agents.

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A suspected case of rocuronium–sugammadex complex-induced anaphylactic shock after cesarean section

Cited by 38 publications

References 17 publications

Preparing for the unexpected: special considerations and complications after sugammadex administration

Preparing for the unexpected: special considerations and complications after sugammadex administration

Severe bradycardia and asystole after sugammadex

An update on allergy and anaphylaxis in pediatric anesthesia

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