Anaphylactic reactions during induction of anaesthesia using rocuronium for muscle relaxation: A report including 3 cases

Abstract

Anaphylaxis during induction of anaesthesia is a dreaded complication with a mortality rate of 3-6%, most frequently associated with the use of muscle relaxants. Current knowledge on this matter is reviewed in relation to the presentation of 3 cases of anaphylaxis and bronchospasm associated with the use of the recently released nondepolarizing muscle relaxant rocuronium. Bronchospasm may be the sole sign of a serious drug reaction, triggered by precipitation of insoluble thiopental crystals when mixed with a muscle relaxant in the intravenous (iv) line. It is recommended that these drugs are administered via different injection ports. The hypotension requires immediate treatment with oxygen, epinephrine and large amounts of iv fluids. Epinephrine infusion may be needed for hours. It is recommended that serum tryptase is measured approximately 2 h after debut of the serious drug reaction. Allergy testing should be performed for all the drugs the patient was exposed to, 4-8 weeks after the incident, and due to cross-reactivity, including all available muscle relaxants. Doctors are urged to inform their patients, and systematically register adverse drug reactions.

IgE and Drug Allergy: Antibody Recognition of ‘Small’ Molecules of Widely Varying Structures and Activities

“…Following a number of reports of anaphylaxis upon administration of rocuronium [39], an immunoassay to detect IgE antibodies to this NMBD has been introduced [40]. Some investigators believe that rocuronium presents an increased risk of anaphylaxis [41][42][43] but others dispute this, claiming the apparent increase in allergic reactions is due to the drug's greater market share [44,45]. An immunoassay for the detection of IgE antibodies to atracurium has recently been examined using sera from a few patients but more studies with the test are needed before its value and reliability can begin to be properly assessed [46].…”

Efeitos hemodinâmicos do atracúrio e do cisatracúrio e o uso de difenidramina e cimetidina

“…Thus, when only one of the histamine receptors (H1 or H2) is blocked, histamine would exert its action on free receptors, promoting an effect of equal magnitude to that observed in the absence of the antagonist 20 . Since H1 and H2 antagonists are competitive, higher doses of those antagonists could be necessary for more complete protection against hemodynamic changes; however, this could promote adverse reactions 2,21 . As for the absence of any effects on the heart rate, H1 antagonists could have had a weak antimuscarinic effect 22,23 , besides the positive chronotropic and inotropic effects of histamine on non-blocked cardiac H2 receptors 23 .…”

“…It is believed that sensitization can result from the use of cosmetics, which have a quaternary ammonium group in their structure, explaining why anaphylactic reaction are three times more common in females than in males 2,3 . Atracurium is a benzylisoquinoline neuromuscular blocker that causes hypotension when administered in doses equal or higher than three times ED 95 5 in humans.…”

“…It is composed by a mixture of ten optical and geometrical isomers 5,6 . The incidence of atracurium-related hypotension is low, but it has been considered the etiologic factor in 18% of the episodes of anaphylaxis during anesthesia 2 . In doses higher than three times its ED 95 in humans, this drug can cause severe hypotension 5,6 .…”

Improvement of suspected rocuronium-induced anaphylaxis after sugammadex administration: A case report

“…First, 100% oxygen is administered, and fluid as well as epinephrine is immediately injected to increase blood pressure [11]. However, Due to the increased permeability of capillary when anaphylaxis occurs, edema can be seen to the lung or respiratory tract if a massive amount of fluid therapy is given, so the presence of the pulmonary edema must be assessed through chest x-ray prior to extubation.…”