Skin Reactions to Intradermal Neuromuscular Blocking Agent Injections

Abstract

The aminosteroidal NMBAs pancuronium, vecuronium, and rocuronium and the benzylisoquinoline cisatracurium have a similar potency to induce a nonspecific skin reactivity. If the criteria for positivity and the maximal concentrations of the commercially available compounds recommended by French practice guidelines are used, the risk of false-positive results is limited, and only minor modifications of these recommendations could be suggested. A slight reduction in the maximal concentration used for rocuronium from 1:100 to 1:200 and an increase from 1:1,000 to 1:200 for mivacurium can be proposed.

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

“…NMBAs have direct vasodilating effects on blood vessels. They are able to induce histamine and tryptase release from mast cells within the skin via different mechanisms that might vary depending on the compounds studied [7]. …”

“…Controversies exist as to the best approach to evaluate rocuronium hypersensitivity reactions. Skin tests in healthy individuals have shown a nonirritating concentration at approximately 10 -4 and 10 -3 M [7]. Fifty percent of healthy individuals show a positive prick test reaction (irritative) with the undiluted drug [8] and current guidelines propose intradermal tests (IDTs) at a dilution of 1:200, i.e.…”

Anaphylaxis during anesthesia in France: An 8-year national survey

“…22,23 Also recorded were the results of plasma histamine (RIA Histamine; Immunotech, Marseille, France) and serum tryptase monitoring (Uni-CAP Tryptase; Phadia SAS, Saint Quentin en Yvelines, France) during the adverse reaction, and of IgE-specific assays testing responses to quaternary ammonium (quaternary ammonium sepharose radioimmunoassay or P-aminophenylphosphoryl-choline radioimmunoassay), 24,25 latex, or antibiotics (Cap System; Phadia SAS) when available. Values above 9 nmol L -1 for histamine and 25 mg L -1 for tryptase were considered positive.…”

Practical Guidelines for Perioperative Hypersensitivity Reactions

“…Therefore, false positive results can occur with drugs such as NMBAs (mivacurium, atracurium, cisatracurium and succinilcoline), thiopental, opioids and some antibiotics such as vancomycin and quinolones. A detailed investigation to determine the maximal nonreactive concentration for NMBAs within healthy subjects has been carried out [118]. The concentrations recommended as non-irritant are shown in Table 2 [31, 119].…”

“…Various scenarios can occur in clinical practice: i) patients have no previous clinical history of perioperative allergic reaction. In these cases there is no indication of performing STs (grade of recommendation, B) [12,118,128] ii) patients with a previous history of reactions, with detailed information available regarding the reaction kinetics and drugs and agents administered. In these cases, STs are mandatory for all the agents administered plus latex [129] and clorhexidine [71,103,104,130] (grade of recommendation, C), however ST results may not be reliable until 4-6 weeks after the initial reaction [131]; iii) Patients with reactions but without clear information about the episode, which is the most complex scenario, especially when there is a long interval between the reaction and the study.…”