Efficacy of sugammadex in rocuronium‐induced or antibiotic‐induced anaphylaxis. A case–control study

Abstract

SummaryWe report 13 cases of presumed rocuronium-induced anaphylaxis in which sugammadex was administered with the intention of reversing the immunological reaction. Of these 13 cases, eight (62%) were later confirmed to be type-1 hypersensitivity reactions to rocuronium, three (23%) were triggered by an antibiotic and two (15%) were non-immunologically mediated. Response to treatment was scored by the treating anaesthetist, and compared with haemodynamic and inotrope measurements from the resuscitation and anaesthetic records. Haemodynamic improvement was seen in only six (46%) cases, three of which were associated with a non-rocuronium trigger. Of the three cases in which the treating anaesthetist thought that sugammadex had been beneficial, one was not caused by rocuronium, one had no improvement in blood pressure and one required 8.5 times as much adrenaline in boluses after, compared with the period before, sugammadex administration. These data suggest that sugammadex does not modify the clinical course of a suspected hypersensitivity reaction.

Non-IgE-Dependent Hypersensitivity to Rocuronium Reversed by Sugammadex: Report of Three Cases and Hypothesis on the Underlying Mechanism

“…However, sugammadex was ineffective in anaphylaxis due to proven rocuronium hypersensitivity [14]. These observations do not argue against our hypothesis, and although we cannot exclude other mechanisms being involved in the rapid clinically favorable response seen in the reported patients, we suggest that sugammadex could be used to reverse pseudoallergic reactions to rocuronium, in addition to standard treatment including adrenaline.…”

“…Once enveloped with sugammadex, rocuronium is unable to bind to the acetylcholine receptor at the neuromuscular junction. Whether sugammadex is useful for antagonizing IgE-mediated or pseudoallergic reactions due to rocuronium remains a matter of debate [14]. …”

Practical Guidelines for Perioperative Hypersensitivity Reactions

“…Sugammadex has been proposed as a useful treatment for anaphylaxis symptoms caused by rocuronium [59,60]. However, in a recently published series of cases, sugammadex did not modify the course of the reaction [61]. Magnesium sulphate may be useful in cases of bronchospasm that are refractory to other treatments [62].…”

A Short Update on Sugammadex with a Special Focus on Economic Assessment of its Use in North America

“…Lately, Raft et al [66] reported that even high doses of sugammadex (14 mgkg -1 ) could be ineffective to reverse a rocuronium-induced anaphylaxis. Platt et al [67] support the inefficacy of sugammadex to reverse rocuronium-induced anaphylaxis publishing the first case-control study on this topic describing 13 patients with a presumed rocuronium-induced anaphylaxis who received a sugammadex injection. They concluded that sugammadex does not interfere with the correction of the immune disorder caused by rocuronium but could improve the hemodynamic parameters by increasing the muscle tone thus increasing cardiac preload [67].…”

“…Platt et al [67] support the inefficacy of sugammadex to reverse rocuronium-induced anaphylaxis publishing the first case-control study on this topic describing 13 patients with a presumed rocuronium-induced anaphylaxis who received a sugammadex injection. They concluded that sugammadex does not interfere with the correction of the immune disorder caused by rocuronium but could improve the hemodynamic parameters by increasing the muscle tone thus increasing cardiac preload [67]. Platt's trial encompasses a substantial methodological flaw because there was no case to use as control [68].…”